Week 2- Principles Of Manual Therapy Flashcards
What percentage of lower back pain is non specific?
85%
What are some of the main specific diagnoses of lower back pain?
Non serious:
- radiculopathy
- spinal canal stenosis
- Spondylolisthesis
- fractures (VB wedge or Spondylolysis)
Serious:
- Malignancies
- Systemic inflammatory disorders
- Infections
- Cauda equina syndrome
What are the 3 key components for treatment of non specific low back pain?
- education and advice
- non pharmacological therapies
- pain relief medications
What does Physiotherapy management of non specific low back pain include in education and reassurance?
- encourage active recovery
- avoid best rest
- remain at work if possible
- resume normal activity
- address miss conceptions eg fear avoidance
- medical imaging not helpful typically
- serious rare
- usually within 2 weeks 1/3 of back pain will be gone, 1/3 within 12 weeks
What is non pharmacological management of non specific low back pain?
Best to combined:
- exercise
- manual therapies
Other techniques with little evidence include
- electro therapy
- heat
- ultrasound
- dry needling
- hydrotherapy
What are the 3 essential for the assessment based clinicians rules?
- are the patients symptoms reflective of a visceral disorder or a serious or potentially life-threatening illness? (Red flags)
- From where is the patient’s pain arising?
- centralisation
- segmental
- neurodynamic
- muscle palpation signs - what has gone wrong with this person as a whole that would cause the pain experience to develop and persist?
Describe the clinical diagnosis flow chart
Describe the flow chart for clinical management
What are signs and symptoms of low back pain suggesting manipulation/ mobilisation as treatment?
- no symptoms distal to the knee
- hypomobility
- recent onset
- Little to no fear
- hip IR >35 degrees (at least one hip)
What are signs and symptoms of low back pain suggesting stabilisation/ motor control as treatment?
- greater general flexibility
- post partum.. positive SIJ provocation
- younger age <40
- positive prone instability test
What are signs and symptoms of low back pain suggesting specific exercises as treatment?
3 specific exercise:
- Extension based
- symptoms distal to buttock, centralised with extension, peripheralise with flexion, directional for extension
2, flexion based
-Directional preference for flexion, older age (>50), imaging evidence of spinal stenosis
- Lateral shift
- visible list, directional preference for lateral flexion
What are signs and symptoms of low back pain suggesting Traction as treatment?
Signs and symptoms of NRC, no movement centralise symptoms
What is the intervention of manipulation mobilisation?
Manipulation mobilisation, with or without active ROM exercise
What interventions for stabilisation, motor control?
Isolated contraction and co contraction of deep stabilisers. Strengthening large spinal stabilisers
What intervention for specific exercise?
- Extension based
- end range extension
- avoid flexion
- mobilisation into extension - Flexion based
Mobilisation manipulation of the spine or lower extremity
Exercise to address impairment in strength/ flexibility - Lateral shift
- exercise is to correct lateral shift
- mechanical traction
What are the 3 presentations of spinal pain?
- Postural syndrome
- end range stress of normal structures - Articular dysfunction
- end range stress of shortened structures - Derangement
- anatomical disruption or displacement within the motion segment
What is centralisation?
When pain moves up the extremity and toward the center of the spine during a movement
What is Peripheralisation?
progressive increase or production of more distal symptoms during the mechanical test or treatment procedures, remain worse
What is the operational definition of derangement?
- change rapidly
- acutely, subacute or chronic
- centralisation or progressive abolition of distal pain in response to repeated movement
- changes in mechanical presentation eg increased ROM
- each progressive abolition retrained over time until all symptoms are abolished
- back pain is also abolished
What is the physical assessment for the McKenzie assessment?
- Standing posture and posture correction on symptoms – E.g., List correction in standing via manual side-glide
- Single movements of flexion, extension and side-gliding
- Repeated movements to establish directional preference
– Flexion in standing and/or lying
– Extension in standing and/or lying
– Side-gliding in standing
What are general principles of force progression?
- Patient forces early through to end range – patient only
- Patient forces end of range with patient overpressure – patient only
- Patient forces with PT overpressure – patient + therapist
- Patient forces with PT overpressure and mobilisation – patient + therapist
Typically signs of derangement syndrome?
- Cause considered to be internal derangement of the disc
- Most common of the syndromes (> 90%)
- Moderate-strong evidence-base for MDT in Lx, and emerging for Cx
- Pain constant or intermittent and located spinal +/- leg and +/- list
- Pain may be aggravated by multiple directions of movement, but there is a directional preference – typically extension eases, flexion worsens
What is the typical 1st session of derangement extension preference?
- Base assessment-standing posture/pain, walking! Lumbar extension AROM
- Prone position, increased flexion with pillows if needed
- Slowly increase lumbar extension every 5-10mins as tolerated, progressing to POE and POEE
- if can’t sustain do prone press ups
- sitting or standing can be done but not as effective
- fix lumbar list first
- expect gradual reduction in peripheral pain even if central pain increases
- avoid lumbar flexion when getting off plinth - re assessment
- Repeat treatment as indicted and teach self management
- Lumbar taping if needed
- Education around self management
What is the education and home program for extension preference
- do every 2-3hrs
- avoid long flexion, sitting
- can use as a preventative
- recommend extension activities
- reassess in clinic in 24-48hrs
What is the follow up treatment involve for the extension preference?
-Continue with Rx as previous and introduce force progressions as req’d.
-Continue with self-management, aim to increase physical activity/participation.
-As patients recover re-introduce Lx flexion movements and postures as tolerated, using
their extension exercises to control symptoms.
-When recovered emphasise the continued use of repeated movement as prophylaxis and to self-manage/control similar episodes of LBP.
What is the Maitland technique?
-PPIVMs + PAIVMs as treatment with grades
• Treatment of dysfunctional physiological or accessory movement
• Most painful, limited or least painful segment, BUT consider adjacent areas
• Comparable sign in appropriate structure
– Assessment - Treatment - Re-assessment
• Evidence within-session changes predict between-session changes, BUT changes in
impairments do not always equal changes in function, SO maximize short-term gains through active exercise and movement
For target segmental pain what are the most common techniques?
- Central PA
- Unilateral PA
- Rotations
What are some signs and symptoms that central PA would be effective?
- symmetrical signs and symmetrical back +/or buttock pain
- comfortable in prone
- stiffness of local intervertebral
- increased symptoms with sitting, coughing and/or sneezing
- limited extension +/- flexion
- symptoms eased by extension
- if list present, PA more effective if patient positioned to correct list in prone
What are some signs and symptoms that central PA would be not effective?
- Asymmetrical symptoms
- uncomfortable in prone
- signs or symptoms suggesting spondylolysis or spondylolisthesis
- release pain
Possible progression of central PA technique?
- strength
- direction altering
- patient posture eg to reduce list or flexion
What are some signs and symptoms that rotations would be effective?
- Asymmetrical symptoms especially with leg pain
- local intervertebral stiffness
- symptoms worse with sitting, coughing or sneezing
What are some signs and symptoms that rotation would be not effective?
- Uncomfortable in side lying
- reproduce distal symptoms
Possible progressions of rotations
- increase strength
- increase speed
- alter direction
- add neural component
What are some signs and symptoms that unilateral PA would be effective?
-asymmetrical symptoms without leg pain
-local intervertebral stiffness
-marked unilateral muscle spasm
-comfortable in prone
+limited extension +/- flexion
What are some signs and symptoms that unilateral PA would be not effective?
- Uncomfortable in prone
- signs and symptoms suggesting spondylolysis or spondylolisthesis
- release pain
- sway back, increased extension in standing
- hypomobilty
Possible progression of unilateral PA
- increase strength
- increase speed/ rhythm
- direction
- transverse of rotation techniques
Treatment of acute wry neck?
PPIVM
Pain free treatment: combined movement in pain free (often also stiffest) direction
May use interim reassessments in supine
Treatment of radiculopathy (lumbar or cervical)
PPIVM
Most relieving (distal over proximal) directional of movement performed in least painful position. Stiffness can also assist to guide treatment direction.
Expect slow changes and may be delayed response
Treatment of whiplash associated disorder?
Be wary manual techniques especially of acute phase. May consider neural movements in painfree range only if symptoms do not increase with continued application of technique.
Be particularly wary of delayed response
Treatment of headaches
PAIVM> PPIVMs
Treat according to local findings
Often need to assess over time, consider frequency, severity and duration
Treatment of acute back pain without list
McKenzie, PAIVM, PPIVM
Stiffer and/ or least painful direction of PAIVM. Less painful direction of PPIVM
Interim reassessment may include standing posture, limit reassessments into flexion
Treatment of acute back pain with list
McKenzie, PPIVM, PAVIM
Attempt to correct list prior to other interventions. Less painful direction PPIVM.stiffer and/or least painful direction of PAIVM.
Interim reassessment may include standing posture, limit reassessments into flexion
Treatment of lumbar canal sternosis
Neural mobs, PPIVM, PAIVM
Avoid working into extension on affected level. Large amplitude, through range movements might be useful both for neural and spinal techniques
Even if get immediate change in movement, need ti asses functionally over time
Treatment of spondylolisthesis
May use rotations if symptoms seem have a discogeniv behaviour
Careful reassessment required including functional assessment over time
Treatment of instability/ hyper mobility
Manual techniques only appropriate if attempting to increase mobility at another location to reduce load on symptomatic location
Why do we use active exercise with manual therapy?
• Effects of MT can be short-lived or latent
• Active exercise alone is generally not recommended/effective
• MT + exercise is more effective than MT or exercise alone
• Active exercise can supplement and/or replicate MT effects:
– Segmental and regional joint mobility
– Muscle relaxation
– Pain relief
– Movement behaviours, thoughts and beliefs
• MT can maximise the effects of exercise through pain reduction, altered motor control, behaviours, thoughts and beliefs
When to use active exercise with manual therapy?
prescribe in conjunction with the MT technique
- patient understands connection between the 2
- reinforce patient centred
- benefits may be lost when exercise is given at the end of a session
Only after isolated effects of the MT are known
- re assessment and/or use clinical experience and pattern recognition
- caution adding in 1st session in irritable patients or when May effect is unknown or unpredictable
How to give active exercise with manual therapy
- Immediately after MT completed and effect established
- Assessment of signs
- explain how and why to perform the exercise and expectation
- target dosage
- Reassessment of signs
- Complete exercise dose in clinic to ensure understanding and response
- Include as home exercise management plan
- pictures, videos
- 2-3 exercise
- little to no equipment
What are some segmental lumbar spine exercise?
- lumbar extensions with hand on lumbar
- side lying lumbar rotations
- MWMs
What are some lumbar spine regional exercises?
- prone push up
- supine leg rolls
- knees to chest
What are segmental thoracic exercises?
- thoracic extensions over chair/ foam roller/ rolled towel
- MWMs
What are regional thoracic exercises?
Cat- camel
What are segmental cervical exercises?
- upper cervical flexions: DNF nodding against wall, 4pt kneel
- MWMs
What are regional cervical exercises?
- Supported Cx movements
- 4pt position Cx movement
- ‘Archery exercise’
