Mobilisation

Question 1

Somatic dysfunction

Answer 1

Somatic dysfunction is defined as impaired or altered function related to components of the somatic system such as muscles, ligaments, bone and joints.

Question 2

Key findings of subjective examination

Answer 2

Site: the area and site of the symptoms are clearly marked on the body chart with symptom details
Stage: Is the problem acute, subacute or chronic?
Severity: The level of pain as determined by the patient. Pain intensity is measured with NRS
Stability: Is the condition improving, staying the same or worsening?
Nature: The patient’s description of their symptoms - mechanical or inflammatory pain?
Irritability: The ease with which the symptoms are provoked, the intensity to which they arise and importantly how quickly they resolve
Progression and rate: How long will the condition take to resolve and how many treatments will be required to achieve this?
Regular or irregular:
Provisional diagnosis

Question 3

Key features of the objective examination

Answer 3

Pain: The pain pattern will have been established in the history taking. This will now be tested against active movement and later passive segmental assessment - both physiological and accessory.
Asymmetry:
ROM: It most often defines the direction of movement loss. Passive intersegmental assessment may add information to the active tests by way of 1. level confirmation, 2. quality of motion, 3. reactivity of tissue to movement
Tissue tension and texture changes:

Question 4

Grading scales (osteopathic model)

Answer 4

Treatment will either be short of the barrier (for a more painful problem) and into the barrier (for a more joint stiffness problem).

Question 5

Indications for manipulation

Answer 5

There are a number of clinical indications that are useful in guiding therapists in the use of an HVT technique

1. As a first option in acute cases (when muscle guarding is not extensive)
2. If the problem is mechanical in nature and fits with a biomechanical pattern that is regular and recognisable
3. There are no contraindications to manipulation and ligament integrity and the absence of VBI signs has been confirmed
4. Where the joint end feel is firm and is consistent with the clinical barrier identified during the mobilisation techniques
5. The patient has been responding favourably through a progression of mobilisation procedures, but has not progressed any further than expected

Question 6

Techniques

Passive intervertebral joint testing (PAIVMs)

Answer 6

PAIVMS are useful for the assessment of joint glide and treatment of acute presentations and elderly patients.

Question 7

Techniques

Passive intervertebral joint testing (PPIVMs)

Answer 7

The head and neck are utilised in such a way as to create locking of the joints above the one to be tested.

Question 8

The type of clinical presentation that would suggest an amenity to manipulative therapy may include

Answer 8

1. primary complaint neck pain
2. A problem that is mechanical in nature and fits with a biomechanical pattern that is regular and recognisable
3. A non-traumatic history of onset suggestive of mechanical dysfunction
4. A limited symptom duration
5. Limited ROM (direction specific) with side-to-side difference
6. Pain that has clear mechanical aggravating and easing positions or movements
7. Local provocation tests produce recognisable symptoms
8. Spinal movement patterns that, when examined actively and passively, suggest a movement restriction that is local to one or two functional units
9. No neurological findings in clinical history or manual assessment
10. No signs of central hyperexcitability
11. No indication that referral to other health care provider is necessary (to exclude red flags)
12. A positive expectation that manipulation will help

Question 9

Clinical subgroup

Convergence pattern

Answer 9

A monosegmental convergence pattern is characterised by pain provocation and motion restriction mainly during extension and ipsilateral side bending and rotation.
This clinical pattern is further clarified by combined passive movement testing.
The intervertebral movement tests may reveal restricted downslope at the same side of the compression pain
A convergence pattern is often found in acute cases and is frequently characterised by a pronounced movement restriction and associated antalgic posture.

Question 10

Clinical subgroup

Divergence pattern

Answer 10

This pattern is considered when pain is provoked and movement is restricted during flexion and contralateral side bending and rotation. The divergence pattern is associated with unilateral stretch pain originating from capsuloligamentous structures, usually appearing at end range of motion.
The intervertebral movement test, performing upslope gliding is usually restricted at the same side of the stretch pain

Question 11

Clinical subgroup

Mixed pattern

Answer 11

This pattern is characterised by multisegmental and multidirectional dysfunctions that can be diagnosed in a degenerative cervical spine. A degenerative cervical spine is characterised by general stiffness, multi-segmental movement restrictions, a mixed pattern of compression/stretch pain.

Question 12

Mobilisation/manipulative techniques

Translatoric techniques

Answer 12

Translatoric techniques are defined as an applied glide or thrust parallel to the zagapophyseal joint plane and are referred to as upslope or downslope techniques. The aim is move the facet joint either up its slope simulating opening of the joint as would occur during flexion and contralateral rotation or down the slope simulating closing of the joint as would occur during extension and ipsilateral side bending.

Question 13

Treatment of convergence pattern

Answer 13

In a 1st phase of treating a convergence pattern any compression at the affected side should be avoided since this would aggravate the condition. Therefore, a direct distraction technique and an indirect gapping approach are both indicated. The primary goal in gapping technique is to obtain pain relief (neurophysiological effect) as the effect on mobility is non-specific.
In 2nd stage the remaining function deficits should be addressed. First, the use of an indirect downslope technique to restore downslope mobility at the affected side is appropriate.
In the final phase, when a painless end range downslope restriction is still present, a direct downslope technique might be warranted.

Question 14

Treatment of divergence pattern

Answer 14

In case of cervical divergence pattern, the main goal is to restore the upslope translation.
Translatoric techniques in the upslope direction are the first choice of treatment in order to restore upslope translation.

Question 15

Basic science mechanisms of manual therapy

Answer 15

Joint mobilisation activates central inhibitory mechanisms to reduce central excitability and have a more widespread effect.

Question 16

When mobilisation should be considered as a therapeutic option

Answer 16

1. Patient complains that impaired movement is their main problem (range and/or quality)
2. Movement impairments are present
3. The patient has a movement disorder for which there is evidence supporting the use of mobilisation in treatment
4. The patient has the feeling that mobilisation can be of help