Manual Therapy - E/W/H

Question 1

Part One: Soft Tissue Techniques

General Soft Tissue Techniques:

• Indication = ?
• Goal = ?
• Examples of ‘Noninvasive ‘ = ?
• Examples of ‘Invasive ‘ = ?

Manual Therapy - E,W,H

Answer 1

General Soft Tissue Techniques:

(a) Indication:

• Patients experiencing myofascial pain, fascial tightness, trigger points, and/or excessive muscle tightness.

(b) Goal:

• Improve myofascial mobility.
• Decrease myofascial pain.
• Prepare the region for additional mobilization.

(c) Noninvasive:

• Bend and Stretch
• Ischemic Compression
• Myofascial Release Holds
• Scar Massage
• Instrument-assisted Soft Tissue Mobilization

(d) Invasive:

• Dry Needling (Deep/Superficial)

Question 2

Part One: Soft Tissue Techniques

Cross-Friction Massage:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 2

Cross-Friction Massage:

(a) Indication:

• This technique is used for patients experiencing tendinopathy (stenosing or inflammatory or degenerative.

(b) Goal:

• Improve Recollagenation
• Discourage Neural Ingrowth
• Decrease Pain

(c) Technique:

Question 3

Part Two: Elbow Mobilization

Humeroulnar Joint
Distraction in Extension = ?

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 3

Humeroulnar Joint
Distraction in Extension

(a) Indication:

• Patients experiencing humeroulnar restriction in extension.

(b) Goal:

• Prepare the Region for Additional Mobilization.
• Improve Capsular Mobility and Range of Motion
• Achieve Terminal Arm Extension

(c) Technique:

• The patient is positioned in supine with their arm on a bolster.
• Arm is positioned in pronation with their cubital fossa pointing up.
• The elbow is pre-positioned in extension
• Distraction force is applied in a posterior-distal direction at 45°
• Curved-gliding force is applied through the other hand in superior, scooping direction.
• Perform this distraction for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education,
• Agonist - Antagonist - Agonist

Question 4

Part Two: Elbow Mobilization

Humeroulnar Joint
Mobilization in Extension:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 4

Humeroulnar Joint
Mobilization in Extension:

(a) Indication:

• This technique is used for patients experiencing humeroulnar restriction in extension.

(b) Goal:

• Improve capsular mobility.
• Improve Range of Motion.

(c) Technique:

• The patient is positioned in side-lying with the involved side down.
• Arm is positioned in pronation with their cubital fossa pointing up.
• The elbow is pre-positioned in extension.
• Mobilization force is applied in a posterior-medial direction at 60°
• Bolster the arm with a strap or sandbag if the upper arm moves.
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 5

Part Two: Elbow Mobilization

Humeroulnar Joint
Distraction in Flexion:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 5

Humeroulnar Joint
Distraction in Flexion:

(a) Indication:

• This technique is used for patients experiencing humeroulnar restriction in flexion.

(b) Goal:

• Prepare the Region for Additional Mobilization.
• Improve Capsular Mobility and Range of Motion

(c) Technique:

• The patient is positioned in side-lying with their arm strapped down.
• Arm is positioned in supination with their medial epicondyle pointing up.
• The arm is pre-positioned in flexion.
• Distraction force is applied in a posterior-distal direction at 45°
• Perform this distraction for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 6

Part Two: Elbow Mobilization

Humeroulnar Joint
Mobilization in Flexion:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 6

Humeroulnar Joint
Mobilization in Flexion:

(a) Indication:

• This technique is used for patients experiencing humeroulnar restriction in flexion.

(b) Goal:

• Improve capsular mobility.
• Improve Range of Motion.

(c) Technique:

• The patient is positioned in side-lying with the involved side down.
• Arm is positioned in supination with their medial epicondyle pointing up.
• Arm is pre-positioned in flexion.
• Mobilization force is applied in a posterior-lateral direction at 60°
• Bolster the arm with a strap or sandbag if the upper arm moves.
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education
• Agonist - Antagonist - Agonist

Question 7

Part Two: Elbow Mobilization

Humeroradial Joint and PRUJ
Distraction and Mobilization in Extension:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 7

Humeroradial Joint and PRUJ
Distraction and Mobilization in Extension:

(a) Indication:

• This technique is used for patients experiencing humeroradial restriction in extension and/or radioulnar joint restriction in pronation.

(b) Goal:

• Improve Capsular Mobility and Range of Motion.
• Achieve Terminal Arm Extension and/or Pronation.

(c) Technique:

• The patient is positioned in sitting with their arm on the table.
• Arm is positioned in supination with their cubital fossa pointing up.
• The elbow is pre-positioned in extension.
• Mobilization force is applied in a posterior-lateral direction at 60°.
• Distraction force is applied along the radius as the arm is brought into pronation.
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 8

Part Two: Elbow Mobilization

Humeroradial Joint and PRUJ
Mobilization in Flexion:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 8

Humeroradial Joint and PRUJ
Mobilization in Flexion:

(a) Indication:

• This technique is used for patients experiencing
• • humeroradial restriction in flexion, and/or
• • radioulnar joint restriction in supination.

(b) Goal:

• Improve Capsular Mobility and Range of Motion.
• Achieve Terminal Arm Flexion and/or Supination.

(c) Technique:

• The patient is positioned in sitting with their arm on the table.
• Arm is positioned in pronation with their cubital fossa pointing up.
• The elbow is pre-positioned in flexion.
• Mobilization force is applied in a anterior-medial direction at 60°.
• Compression force is applied along the radius as the arm is brought into supination.
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 9

Part Three: Wrist and Hand Mobilization

Distal Radioulnar Joint
Mobilization in Supination or Pronation:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 9

Distal Radioulnar Joint
Mobilization in Supination or Pronation:

(a) Indication:

• This technique is used for patients experiencing radioulnar joint restriction in supination or pronation.

(b) Goal

• Improve Capsular Mobility and Range of Motion.
• Achieve Terminal Arm Supination or Pronation.

(c) Technique:

• The patient is positioned in sitting with their arm on the table.
• Arm is positioned in the position of their restriction (Supination or Pronation).
• • Supination: Mobilization force is applied to the volar surface of the radius in a posterior direction along the joint line.
• • Pronation: Mobilization force is applied to the dorsal surface of the radius in an anterior direction along the joint line (pictured right).
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 10

Part Three: Wrist and Hand Mobilization

Radiocarpal Joint
Volar Mobilization in Extension:

Manual Therapy - E,W,H

Answer 10

Radiocarpal Joint
Volar Mobilization in Extension

(a) Indication:

• This technique is used for patients experiencing radiocarpal restriction in extension.

(b) Goal

• Improve Capsular Mobility and Range of Motion.
• Achieve Terminal Wrist Extension.

(c) Technique:

• The patient is positioned in sitting with their arm on the table.
• Arm is positioned in wrist extension.
• Stabilizing force is applied to the distal radius and ulna.
• Mobilization force is applied to the dorsal surface of the proximal carpal row in a volar direction.
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 11

Part Three: Wrist and Hand Mobilization

Radiocarpal Joint
Dorsal Mobilization in Flexion:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 11

Radiocarpal Joint
Dorsal Mobilization in Flexion

(a) Indication:

• This technique is used for patients experiencing radiocarpal restriction in flexion.

(b) Goal

• Improve Capsular Mobility and Range of Motion
• Achieve Terminal Wrist Flexion

(c) Technique:

• The patient is positioned in sitting with their arm on the table.
• Arm is positioned in wrist flexion
• Stabilizing force is applied to the distal radius and ulna.
• Mobilization force is applied to the volar surface of the proximal carpal row in a dorsal direction.
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 12

Part Three: Wrist and Hand Mobilization

Radiocarpal Joint
Medial Mobilization in Radial Deviation:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 12

Radiocarpal Joint
Medial Mobilization in Radial Deviation:

(a) Indication:

• Patients experiencing radiocarpal restriction in radial deviation.

(b) Goal

• Improve Capsular Mobility and Range of Motion.
• Achieve Terminal Wrist Radial Deviation.

(c) Technique:

• The patient is positioned in sitting with their arm on the table and their hand and wrist off the table.
• Wrist is positioned in Radial Deviation and Slight Flexion (not pictured).
• Stabilizing force is applied to the distal radius and ulna.
• Mobilization force is applied to the lateral surface of the proximal carpal row in a medial direction.
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 13

Part Three: Wrist and Hand Mobilization

Intercarpal Joint
Volar/Dorsal Mobilization or Manipulation:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 13

Intercarpal Joint
Volar/Dorsal Mobilization or Manipulation:

(a) Indication:

• This technique is used for patients experiencing carpal restriction in flexion or extension.

(b) Goal:

• Improve Capsular Mobility and Range of Motion
• Achieve Terminal Wrist Flexion or Extension

(c) Technique:

• The patient is positioned in sitting with their hand held in yours.
• Wrist is brought from Neutral into Extension or Flexion.
• • (Extension) Mobilization/Manipulation force is applied to the dorsal surface of the hypomobile carpal with overlapping thumbs (pictured).
• • (Flexion) Mobilization/Manipulation force is applied to the volar surface of the hypomobile carpal with overlapping index fingers (not pictured).
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Perform this manipulation 1-2 times
• Finish the technique with neuro-muscular re-education
• Agonist - Antagonist - Agonist

Question 14

Part Three: Wrist and Hand Mobilization

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 14

(a) Indication
(b) Goal
(c) Technique

Question 15

Part Three: Wrist and Hand Mobilization

Radiocarpal Joint
Lateral Mobilization in Ulnar Deviation:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 15

Radiocarpal Joint
Lateral Mobilization in Ulnar Deviation:

(a) Indication:

• This technique is used for patients experiencing radiocarpal restriction in ulnar deviation.

(b) Goal:

• Improve Capsular Mobility and Range of Motion.
• Achieve Terminal Wrist Ulnar Deviation.

(c) Technique:

• The patient is positioned in sitting with their arm on the table and their hand and wrist off the table.
• Wrist is positioned in Ulnar Deviation and Slight Extension.
• Stabilizing force is applied to the distal radius and ulna.
• Mobilization force is applied to the medial surface of the proximal carpal row in a lateral direction.
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 16

Part Three: Wrist and Hand Mobilization

Intercarpal Joint
Volar/Dorsal Mobilization or Manipulation:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 16

Intercarpal Joint
Volar/Dorsal Mobilization or Manipulation

(a) Indication
(b) Goal
(c) Technique

• The patient is positioned in sitting with their hand held in yours.
• Wrist is brought from Neutral into Extension or Flexion.
• • (Extension) Mobilization/Manipulation force is applied to the dorsal surface of the hypomobile carpal with overlapping thumbs (pictured)
• • (Flexion) Mobilization/Manipulation force is applied to the volar surface of the hypomobile carpal with overlapping index fingers (not pictured)
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Perform this manipulation 1-2 times.
• Finish the technique with neuro-muscular re-education
• Agonist - Antagonist - Agonist

Question 17

Part Three: Wrist and Hand Mobilization

1st Carpometacarpal
Distraction:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 17

1st Carpometacarpal
Distraction

(a) Indication:

• This technique is used for patients experiencing carpometacarpal restriction or pain at the 1st finger.

(b) Goal:

• Improve Pain
• Improve Capsular Mobility and Range of Motion
• Prepare Tissue for Additional Mobilization

(c) Technique:

• The patient is positioned in sitting with their arm on the table.
• Stabilizing force is applied to the distal carpal row.
• Distraction force is applied along the axis of the 1st metacarpal.
• Perform this mobilization for 4x 30-45 sec., or until capsular change/pain reduction

Question 18

Part Three: Wrist and Hand Mobilization

1st Carpometacarpal
Mobilization:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 18

1st Carpometacarpal
Mobilization:

(a) Indication:

• This technique is used for patients experiencing carpometacarpal restriction of the 1st.

(b) Goal:

• Improve Capsular Mobility
• Achieve Terminal Thumb Range of Motion

(c) Technique:

• The patient is positioned in sitting with their arm on the table.
• Stabilizing force is applied to the distal carpal row.
• Mobilization force is applied to the base of the 1st metacarpal.
• • Flexion: Medial force applied to the Lateral surface
• • Extension: Lateral force applied to the Medial surface.
• • Abduction: Dorsal force applied to the Palmar surface.
• • Adduction: Palmar force applied to the Dorsal surface (difficult to access).
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 19

Part Three: Wrist and Hand Mobilization

Metacarpophalangeal Joint
Distraction or Mobilization:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 19

Metacarpophalangeal Joint
Distraction or Mobilization:

(a) Indication:

• This technique is used for patients experiencing metacarpophalangeal pain or restriction in flexion/extension or abduction/adduction.

(b) Goal:

• Improve Pain
• Improve Capsular Mobility
• Achieve Terminal Finger Range of Motion

(c) Technique:

• The patient is positioned in sitting with their arm on the table.
• Stabilizing force is applied to the distal metacarpal.
• Mobilization force is applied to the base of the 1st phalanx
• • Flexion: Volar force applied to the Dorsal surface
• • Extension: Dorsal force applied to the Volar surface
• • Abduction: Force is applied away from the 3rd finger
• • Adduction: Force is applied toward the 3rd finger.
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist

Question 20

Part Three: Wrist and Hand Mobilization

Interphalangeal Joint
Distraction or Mobilization:

• Indication = ?
• Goal = ?
• Technique = ?

Manual Therapy - E,W,H

Answer 20

Interphalangeal Joint
Distraction or Mobilization

(a) Indication:

• This technique is used for patients experiencing radiocarpal restriction in ulnar deviation.

(b) Goal:

• Improve Capsular Mobility and Range of Motion.
• Achieve Terminal Wrist Ulnar Deviation

(c) Technique:

• The patient is positioned in sitting with their arm on the table.
• Stabilizing force is applied to the distal portion of the proximal phalanx.
• Mobilization force is applied to the proximal portion of the distal phalanx.
• • Flexion: Volar force applied to the Dorsal surface.
• • Extension: Dorsal force applied to the Volar surface.
• Perform this mobilization for 4x 30-45 sec., or until capsular change.
• Finish the technique with neuro-muscular re-education.
• Agonist - Antagonist - Agonist