Week 4 Flashcards
What is motor control?
Ability to regulate or direct mechanisms essential to movement
Movement is constrained by factors related to the ___
- Individual
- Task
- Environment
Movement ___ from the constraints
Movement emerges from the constraints
The individual generates movement to meet the demands of ___ within the specific ___
The individual generates movement to meet the demands of task within the specific environment
True or false
We prescribe a movement
False
We DO NOT prescribe a movement
What are the systems underlying motor control that is contributed by the individual?
- Motor/action
- Sensory/perceptual
- Cognitive
What systems are in charge of the motor/action systems underlying motor control?
- Neuromuscular system
- Bio-mechanical system
What are degrees of freedom?
The number of independent position variables that are necessary to specify the state of a structure
How many degrees of freedom are in the whole body?
244
What controls/manages the degrees freedom?
The motor/action motor control system
What is the sensory portion of the sensory/perceptual system underlying motor control?
Information that is taken in from the peripheral sensory organs and nerve endings for things like light touch, proprioception, pain and temp
What is the perceptual portion of the sensory/perceptual system underlying motor control?
The integration of sensory information into meaningful information and it involves a lot of higher level processing
If you have normal ____, you have to have normal ____
If you have normal perception, you have to have normal sensory
You can have normal ___, but have abnormal ___
You can have normal sensory, but have abnormal perception
What is involved in the cognitive system underlying motor control?
Attention, planning, problem solving, motivation, and emotional aspects that underlie intent/goals of movement
What are the categories of task in the task constraints?
- Discrete vs Continuous
- Closed vs. Open
- Stability vs. Mobility
- Manipulation vs. Non-manipulation task
What are the distinguishing attributes in the discrete category of task?
Discrete movement task such as kicking a ball or moving from sitting to standing or lying down have a recognizable beginning and end
What are the distinguishing attributes in the continuous category of task?
In continuous movements such as walking or running, the end point of the task is not an inherent characteristic of the task, but is decided arbitrarily by the performer
What are the distinguishing attributes in the open movements category of task?
Open movement tasks such as playing soccer or tennis require performers to adapt movement strategies to a constantly changing and often unpredictable environment
What are the distinguishing attributes in the closed movements category of task?
Closed movement task are performed in relatively fixed or predictable environment
What are the distinguishing attributes in the stability movements category of task?
Stability tasks such as sitting or standing are performed with a non-moving base of support
What are the distinguishing attributes in the mobility movements category of task?
Mobility tasks such as walking or running require moving the bas of support
What are the distinguishing attributes in the manipulation movements category of task?
Manipulation tasks involve movement of the upper extremities
A closed/predictable environment coupled with a stability/ nonmoving BOS creates what type of task constraint?
Sitting or standing on a nonmoving surface
A closed/predictable environment coupled with a mobility/ moving BOS creates what type of task constraint?
Walking/nonmoving surface
An open/unpredictable environment coupled with a mobility/ moving BOS creates what type of task constraint?
Walking on an uneven or moving surface
An open/unpredictable environment coupled with a stability/nonmoving BOS creates what type of task constraint?
Sitting or standing on a foam or rocker board
What are the 2 environmental constraints of motor control?
- Regulatory features
- Non-regulatory features
What are the regulatory features of the environmental constraints?
Things that shape/direct movement
What are the non-regulatory features of the environmental constraints?
May impact performance, but doesn’t define movements
What are the 3 tasks that contribute to movement?
- Postural control
- Upper extremity function
- Mobility
What are motor control theories?
Description of unobservable structures and processes and their relationship to observable events
What does the reflex theory say?
Movement is a sum of reflexes that was strung together and that sensation is necessary for the reflexes to generate movement
Why isn’t the reflex theory true?
- We can turn off reflexes
- Sensation is not required for movement
- We can anticipate something that will require movement to be altered
What does the hierarchical theory/top down model say?
The brain is in control of movement and it drives everything below, and when we have damage to the higher centers/brain things in the lower centers go wonky, because they don’t have the inhibition from the higher centers
Why isn’t the hierarchical theory true?
- We can disconnect the spinal cord from the brain and the re will still be movement
- Reflexes come and go as needed as opposed to being controlled by the brain
What does the motor programming theory say?
We have a pattern/program for every motion that is needed to occur and we store the rules for general movement somewhere in the body, and there is no need for sensation
Why isn’t the motor programming theory true?
- We have too many degrees of freedom to be able to control with general programmed rules
- Cognitive storage will be too large
- Much of our movement is context dependent, and we can’t have a stored pattern for an unfamiliar context
What does the systems theory say?
Control is distributed across various systems, sometimes it was the higher control systems, other times the reflexes, or centers in between. Interactive, cooperative system, where movement occurred based on internal and external forces
Why isn’t the systems theory true?
IDK, there is no real contradictory evidence to it
___ is a further projection of the systems theory
*The dynamic action (dynamic systems) is a further projection of the systems theory
The dynamic action (dynamic systems) theory is based on the idea of ___ and movement emerges as a result of ___
The dynamic action (dynamic systems) theory is based on the idea of self-organization and movement emerges as a result of interacting elements
What does the ecological theory say?
Information from the environment controls movement. Motor control evolved to cope with environment around us and perception is the key element to movement
What is the well accepted theory of motor control?
The dynamic action (dynamic systems) theory
Which motor control theory is the best?
None of them, motor control is a combination of a number of the theories
What is motor learning?
The acquisition and or modification of movement or the reacquisition of movement skills lost after an injury.
Motor learning talks about the ___
The process associated with practice or experience leading to permanent changes in skill
Motor learning is the ___ of acquiring capability for skill, that results from ___ or ____
Motor learning is the process of acquiring capability for skill that results from experience or skill
How is the concept of motor learning measured?
It is inferred from behavior
Motor learning produces relatively ___ changes in behavior
Motor learning produces relatively permanent changes in behavior
When is learning assumed to have taken place?
Learning can only be assumed to have taken place when patient can perform task effectively and without thinking about it in a variety of circumstances and contexts
Motor learning is learning new strategies for ____ as well as moving
Motor learning is learning new strategies for sensing as well as moving
Motor learning emerges from ____
Motor learning emerges from perception, cognition, action processes
Motor learning is described as a search for ____, emerging from ____
Motor learning is described as a search for task solution, emerging from interaction of individual with task and environment
Motor learning emerges from the interaction of the ___
- Task
- Environment
- Individual
How do you test for retention in a patient’s motor learning?
There has to be a break in practice, then retest after the break. If the skill is at the same level as at the end of practice, then we have retention, hence true motor learning has occurred
What are the 2 types of long-term memory?
- Declarative memory
- Non declarative memory
Declarative memory is also known as ___ memory
Declarative memory is also known as explicit memory
Non declarative memory is known as ___ memory
Non declarative memory is known as implicit memory
The types of learning that occurs in declarative memory requires ____
The types of learning that occurs in declarative memory requires conscious processes like awareness, attention, and reflection
What are the types of learning in the declarative memory?
- Semantic
- Episodic
What does semantic learning mean/entail?
The recall of facts. Book learning, knowledge
What does episodic learning mean/entail?
Memories related to events
When do we use declarative memory in learning?
When we are teaching a series/steps of tasks and hopefully it transfers to the non-declarative memory
What are the types of learning in the non-declarative memory?
- Procedural (skills & habits)
- Priming
- Non associative learning
What is procedural learning?
When learning a task can be performed automatically without attention or thought, like a habit
Procedural learning develops ____
Procedural learning develops slowly through, repetition over many trials
Procedural learning is expressed through ___
Procedural learning is expressed through improved performance of the task
True or false
Procedural learning requires awareness, attention, or higher cognitive processes
FALSE
Procedural learning DOES NOT requires awareness, attention, or higher cognitive processes
What area of the brain does semantic learning occur?
Cortical association areas
What area of the brain does episiodic learning occur?
Medial temporal lobe & neocortex
What area of the brain does procedural learning occur?
Striatum
What area of the brain does conditioning learning occur?
Amygdala
What area of the brain does nonassociative learning occur?
Reflex pathways
What are the 2 forms of non-associative learning?
- Habituation
- Sensitization
We use habituation to treat patients with ___
We use habituation to treat patients with dizziness related vestibular problem, by exposing them to the conditions that make them dizzy in order to habituate them/ make them less affected by it
What is conditioning?
The type of learning where we predict relationships of one stimulus to another
What are the 2 forms of conditioning?
- Classical
- Operant
What is operant conditioning?
Trial and error learning, where we associate a certain response with a specific consequence
What does the Schmidt’s Schema theory talk about?
Open loop control and generalized motor program. Motor programs as generalized rules for specific types of movements or schema
In the schmidt’s schema theory, there is a ____ and ___ schema
In the schmidt’s schema theory, there is a recall and recognition schema
In the schimdt’s schema theory, what are the 4 things that are available for short term memory?
- The initial movement conditions
- The parameters used in the general motor program
- The outcome of the movement in terms of knowledge of results
- Sensory information/consequences of the movement
What is recall used for in the schimdt’s schema theory?
To select a specific response
What is recognition used for in the schimdt’s schema theory?
To evaluate the outcome of the specific response chosen in the recall
The schimdt’s schema theory predicted that variability of practice improved ___
The schimdt’s schema theory predicted that variability of practice improved motor learning
What are the limitations of the schimdt’s schema theory?
Support is mixed for variable practice, doesn’t account for immediate acquisition of coordination
What does the ecological theory state?
We search strategies for optimal strategies to solve task, given a task constraint
According to the ecological theory, motor learning is task that increases coordination between ___ and ____
According to the ecological theory, motor learning is task that increases coordination between perception and action
In the ecological theory, there need to be exploration of ___/___ workspace
In the ecological theory, there need to be exploration of perceptual/motor workspace
What is perception in the ecological theory?
Understanding goal, feedback, structures
What are the stages in the fitts and posner 3-stage model of motor learning?
- Cognitive stage
- Associative stage
- Autonomous stage
What is included in the cognitive stage of the fitts and posner 3-stage model of motor learning?
- Acquisition of knowledge
- Trial and error stage
What is included in the associative stage of the fitts and posner 3-stage model of motor learning?
- Refining of skill
- Less variability
What is included in the autonomous stage of the fitts and posner 3-stage model of motor learning?
- Automaticity of skill
- Low degree of attention
What is the key component of the bernstein’s 3 stage model?
Controlling or mastering degrees of freedom (DOF)
What are the 3 stages in the bernstein’s 3 stage model?
- Novice stage
- Advance stage
- Expert stage
What is included in the novice stage of the bernstein’s 3 stage model?
Simplify movements to decrease DOF
What is included in the advance stage of the bernstein’s 3 stage model?
Gradual release of DOF
What is included in the expert stage of the bernstein’s 3 stage model?
Release of all DOF
What is the stage 1 goal of the gentile’s two-stage model?
Develop understanding of dynamics of task
What are the task dynamics of the stage 1 goal of the gentile’s two-stage model?
- What are the requirements of movement?
- What is the goal/environment of the movement?
What is the stage 2 goal of the gentile’s two-stage model?
Refining the movement, performing it consistently and efficiently. Fixation and diversification
___ is an important stimulant for neuroplastic change and remediation of maladaptive
patterns
Task specific motor learning is an important stimulant for
neuroplastic change and remediation of maladaptive
patterns
Brain continuously remodels to encode ___and cause ____
Brain continuously remodels to encode new experiences and cause behavior change
Plasticity is dependent upon ___
Plasticity is dependent upon learning
Skill learning leads to rewiring of ____
Skill learning leads to rewiring of motor cortex
Recovery/functional improvement is a ____ process
Recovery/functional improvement is a relearning process
The brain relies on ___ neurobiological processes when relearning a skill, that it used to acquire skill initially
The brain relies on the same neurobiological processes when relearning a skill, that it used to acquire skill initially
____ not ____ leads to increased numbers of synapses in motor cortex
Motor learning, not motor activity leads to increased numbers of synapses in motor cortex
What is the PT goal for all patients?
Recovery
What does recovery mean for patients?
• Restoring function in neural tissue that was lost
• Restoring ability to perform movements in same manner as
premorbid
• Successful task accomplishment using typical “parts”
What does compensation entail as it regards to patient function?
- Neural tissue acquires function it didn’t have premorbid
- Performing old movements in a new way
- Successful task completion using alternative “parts”
Recovery is ____ changes in neural activation, organization, and structure
Recovery is permanent changes in neural activation,
organization, and structure
Recovery is a restoration /remodeling toward ___ state of organization
Recovery is a restoration /remodeling toward NORMAL state of organization
What is compensation?
Compensation is a behavioral substitution; alternative behavioral strategies adopted to complete the task; use of remaining parts
Compensation leads to ___
Compensation leads to learned non-use
Compensation creates conditions in which CNS does not engage in___
Compensation creates conditions in which CNS does not engage in processing critical for recovery of motor control
Compensation may itself be the primary reason that ___ remain.
Compensation may itself be the primary reason that motor deficits remain.
What are the mechanisms by which functional improvement can occur?
Recovery and Compensation
Both mechanisms by which functional improvement can occur can be observed at ____ and ____ levels
Both mechanisms by which functional improvement can occur can be observed at behavioral and neural levels
Recovery of function is a ____ neuroplasticity, while compensation is a ____ neuroplasticity
Recovery of function is a positive neuroplasticity, while compensation is a negative neuroplasticity
Compensatory behaviors are key in ___ response to brain injury
Compensatory behaviors are key in “normal” response to brain injury
Reliance on less-affected limb is associated with ___ and ___ in non-affected hemisphere
Reliance on less-affected limb associated with reorganization and neuronal growth in non-affected hemisphere
Patients often can only make ___ solutions that eliminate the ____
Patients often can only make short term solutions that eliminate the long term
possibilities.
What is the goal of motor rehab?
The goal of motor rehab is to
facilitate the neural reorganization that underlies relearning of motor skills and function following damage to the CNS
According to the WHO, what is health?
The state of complete physical, mental, and social well being, and not merely the absence of disease
The ICF model can characterized as a ____
The ICF model can characterized as a *biopsychosocial model that integrates abilities and disabilities and provides a coherent perspective of various aspects of human functioning and disability as they relate to the continuum of health
The ICF model is designed to put less emphasis on ___ and greater emphasis on how ____
The ICF model is designed to put less emphasis on disease and greater emphasis on how people who are affected by health conditions live
What is classification?
A tool for organizing the knowledge of complex relationships among health status, functioning and disability in a useful way
Classification delivers a foundation for ___
Classification delivers a foundation for *effective health care services, and the theoretical framework upon which practice can be organized and research can be based
Classification can facilitate ___
Classification can facilitate effective management and care of patients reflected by the integration of meaningful functional outcomes
According to the ICF model, health conditions are ___
According to the ICF model, health conditions are acute or chronic diseases, disorders or injuries that have an impact on a person’s level of activity
How are health conditions characterized?
By a set of abnormal findings indicative of alterations or interruptions of structure or function of the body and are primarily identified at the cellular, tissue, or organ system level
Health condition is generally the basis of a ____
Health condition is generally the basis of a medical diagnosis conserved to trigger medical intervention
What are the two basic components of the ICF model?
- Functioning and disability
- Contextual factors
The functioning and disability component of the ICF model can be divided into __
- Body functions and structure
- Activity
- Participation
Impairments in body function include problems with ___
Impairments in body function include problems associated with the function of body systems including physiological and psychological functions
Impairments in body structure include problems with ___
Impairments in body structure include problems with anatomical features of the body, such as significant deviation, or loss affecting all body systems
Activity limitations include ____
Activity limitations include difficulties an individual may have in executing actions, tasks or activities
Participation restrictions include problems an individual may experience in ___
Participation restrictions include problems an individual may experience in involvement in life situations, including difficulties in participating in self care, responsibilities in the home, workplace, or community and recreational, leisure or social activities
The contextual factor component of the ICF model include __
- Environmental factors
- Personal factors
Environmental factors include factors associated with ___
Environmental factors include factors associated with physical, social, and attitudinal environment in which people conduct their lives
Environmental factors may serve as ___
Environmental factors may serve as facilitators of functioning or barriers that hinder functioning
Personal factors include ____
Personal factors include features of the individual that are not part of the health condition or health state, such as age, gender, race, lifestyle habits, coping skills, character, affect, cultural or social background and education
Does adverse changes in one component of the ICF model have adverse effects on the other components?
No it doesn’t
According to the guide to PT practice, what is an intervention?
Purposeful interaction of the physical therapist with an individual to produce changes in the condition that are consistent with the diagnosis and prognosis
When does intervention occur in PT?
- Multiple point during evaluation and examination as well as after the PT has determined the diagnosis, prognosis, and POC
What is the selection of interventions based upon?
- Examination findings including data collected from the history, systems review and tested measures
- Evaluation and a diagnosis that supports PT intervention
- A prognosis that is associated with improved or maintained health status through risk reduction, health wellness and fitness programs, or the remediation of impairments, activity limitations, participation restrictions or environmental barriers
- Goals and outcomes that have been developed in collaboration with the individual
Impairments can be seen as ___
Impairments can be seen as consequences of pathological conditions, encompassing signs and symptoms that reflect abnormalities at the body system, organ or tissue level
Impairments of __, ___, and ____functions and structures of the body are a reflection of a person’s health status
Impairments of physiological, anatomical, and psychological functions and structures of the body are a reflection of a person’s health status
PTs provide care to patients with impairments of ___ and or ___ that are part of the movement system as a whole
PTs provide care to patients with impairments of body function and or body structure that are part of the movement system as a whole
What are the common MSK disorders managed through PT intervention?
- Pain
- Muscle weakness/reduced torque production
- Decreased muscular endurance
- Limited range of motion
What are the common neuromuscular disorders managed through PT intervention?
- Pain
- Impaired balance, postural stability, or control
- Incoordination, faulty timing
- Delayed motor development
- Abnormal tone (hypotonia, hypertonia, dystonia)
- Ineffective/inefficient functional movement strategies
What are the common cardiovascular/pulmonary disorders managed through PT intervention?
- Decreased aerobic capacity
- Impaired circulation
- Pain with sustained physical activity
Limited ROM could be due to..?
- Restriction of the joint capsule
- Restriction of peri-articular connective tissue
- Decreased muscle length
- Joint hypomobility
Primary impairments arise directly from ___
Primary impairments arise directly from the health condition
Secondary impairments are the result of ___
Secondary impairments are the result of preexisting impairments
Primary impairments could include ___
- Pain
- Limited ROM
- Weakness
Composite impairments occur as a result of ___ and arises from _____
Composite impairments occur as a result of multiple underlying causes and arises from a combination of primary or secondary impairments
In PT the impairment based approach of care is …..?
In PT the impairment based approach of care is a straight forward one. If there is stiffness, we stretch, and so on. But this is no bueno on its own
What are the key point in managing impairments?
- Impairments manifest differently from one patient to another
- Not all impairments are necessarily linked to activity limitations and participation restrictions or lead to disability
- Important key to effective management is recognition of functionally relevant impairments
- Elimination or reduction of functionally relevant impairments is necessary during treatment
What are the strategies for establishing relevance?
- When possible, use reliable and valid tests with known predictive validity
- Consider when testing of an impairment alters familiar
symptoms - Consider when intervention to address an impairment
corresponds with positive changes in signs and/or symptoms - Consider when improvements in an impairment correspond with positive changes in signs and/or symptoms
Activity limitations, which is analogous with functional limitations occur at the level of the ___
Activity limitations, which is analogous with functional limitations occur at the level of the whole person, when a patient has difficulty executing or is unable to perform tasks or actions of daily life
Activity limitations may be ___, ___, or ___ in nature
Activity limitations may be physical, social, or psychological in nature
True or false
Interventions that directly address activity limitations may be beneficial in rehabilitation
True
What is an activity based approach?
An intervention approach addressing Activity Limitations
Overlap in activity limitation and impairment does what for the PT?
- May establish relevance
* Activity-based approach often able to address impairments
Participation restrictions and disability include ___
Participation restrictions and disability include problems a person may experience in involvement in life situations as measured against social
standards
What are some of the areas of functioning associated with participation restrictions and disability?
- Self-care
- Mobility in the community
- Occupational tasks
- School-related tasks
- Home management (indoor and outdoor)
- Caring for dependents
- Recreational and leisure activities
- Socializing with friends/family
- Community responsibilities and service
___ is the core of patient- centered care
Attention upon reducing participation restrictions is the core of patient- centered care
What are the things that can make intervention meaningful to an individual receiving care?
Reducing disability and improving participation in relevant areas of function
The ICF can help the PT organize the clinical data collected through the ___ and __ processes, such that the inner relationships between an individual’s health condition, functioning and disability, and contextual factors can be considered in making meaningful decisions for the person as a whole
The ICF can help the PT organize the clinical data collected through the examination and evaluation processes, such that the inner relationships between an individual’s health condition, functioning and disability, and contextual factors can be considered in making meaningful decisions for the person as a whole
What is manual therapy?
Skilled hand movements and skilled passive movements of joints and soft tissue
What are some manual therapy techniques?
- Manual lymphatic drainage
- Manual traction
- Massage
- Mobilization/manipulation
- Neural tissue mobilization
- Passive range of motion
What are the intentions of manual therapy as it relates to body functions and structure
Impairments?
• Improve tissue extensibility • Increase range of motion • Induce relaxation • Mobilize or manipulate soft tissue and joints • Modulate pain • Reduce soft tissue swelling, inflammation, or restriction
What are the intentions of manual therapy as it relates to activity limitations/
participation restrictions?
• Enhance health, wellness, and fitness • Enhance or maintain physical performance • Increase the ability to move • Improve physical function
What is mobilization/manipulation?
Manual therapy techniques
comprising a continuum of skilled passive movements to joints and/or related soft tissues at varying speeds and amplitudes, including a
small-amplitude/high-velocity therapeutic movement
What are the criterias included in the description of mobilization/manipulation?
- Rate of force application
- Location in range of
available movement - Direction of force
- Target of force
- Relative structural
movement - Patient position
What is the rate of force application in the description of mobilization/manipulation?
Describes the rate at which the force is applied
The location in range of available movement describes ___
The location in range of available movement describes whether motion is intended to occur only at the beginning of the available range of movement, towards the middle of the available range of movement, or at the end point of the available range of movement
The direction of force describes ___
The direction of force describes the direction in which the therapist imparts the
force
The target of force describes the ____
The target of force describes the location to which the therapist intends to apply the force
The relative structural movement describes which ___
The relative structural movement describes which structure or region is intended to remain stable and which structure or region is intended to move, with the moving structure or region being named first and the
stable segment named second, separated by the word “on”
The patient position describes the ___
The patient position describes the position of the patient, for example, supine, prone, or recumbent. This would include any pre-manipulative positioning of a region of the body, such as being positioned in rotation or side bending.
What are the 3 primary principles of the “law of the artery” according to osteopathic medicine?
- The body is a unit
- Structure and function are reciprocally inter-related
- The body possesses self regulatory mechanisms for rational therapies based on an understanding of body unity, self-regulatory mechanism, and the inter relations structure and function
According to osteopathic medicine, addressing ___ within the ___ could be used to improve health and treat diseases
According to osteopathic medicine, addressing somatic dysfunction within the musculo-skeletal system could be used to improve health and treat diseases
Chiropractic is based on the ____
Chiropractic is based on the law of the nerve
What is the subluxation theory according to the law of the nerve?
A vertebrae becomes subluxed, impinging on other structures such as nerves, blood vessels and lymphatics, passing through the intervertebral foramen and as a result, the function of the corresponding segment of the spinal cord and its connecting spinal and autonomic nerves is interfered with and the function of nerve impulses is impaired
Most of the historical perspective on mechanisms of manual therapy focuses on ___
Most of the historical perspective on mechanisms of manual therapy focuses on select biomechanical and
pathoanatomic constructs
What are are mechanical mechanisms of manual therapy?
- Joint motion with at least transient biomechanical effects
- No evidence for lasting positional change
- Forces are dissipated over a large area
- Difficult to assert specificity of techniques
- Kinetic parameters vary widely among clinicians performing same technique
Interactions between ___ and ____ may be affected by manual therapy
Interactions between inflammatory mediators and peripheral nociceptors may be affected by manual therapy
What are the spinal neurophysiological mechanisms as it relates to manual therapy?
- Manual therapy may act as a counter irritant to modulate pain by bombarding central nervous system with sensory
input from proprioceptors - Decreased activity dorsal horn of the spinal cord following manual therapy
- Neuromuscular responses such as changes in afferent discharge, motoneuron pool activity, and muscle activity
- Hypoalgesia via inhibition of temporal summation
and selective blocking of neurotransmitters
What is one of the most powerful mechanism through which manual therapy exerts its effects?
Supraspinal Neurophysiological
Mechanisms
____ can be viewed as a desirable response to manual therapy and considered a physiological process following manual therapy
Placebo analgesia can be viewed as a desirable response to manual therapy and considered a physiological process following manual therapy
What are the physiological responses of placebo analgesia following manual therapy?
• Decreased activity dorsal horn of the supraspinal regions responsible for
changes in central pain processing following manual therapy
• Potential descending inhibition due to associated changes in the autonomic
responses, opioid system, dopamine production, and central nervous system
What are the psychological responses of placebo analgesia following manual therapy?
• Psychosocial factors may be pertinent in mechanisms of manual therapy
- Expectation of effectiveness
- Conditioning
• Negative emotions are known to diminish placebo effects
Which mechanisms are greater contributor to the effects observed in the association of clinical use of manual therapy techniques?
Neurophysiological Mechanisms
What is regional interdependence?
With respect to MSK problems, regional interdependence refers to the
concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated
with, the patient’s primary complaint
What are the mechanisms of regional interdependence?
- MSK
- Somatovisceral
- Biopsychosocial
- Neurophysiological
What is the redefination of regional interdependence?
The concept that a patient’s primary musculoskeletal symptom(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptom(s)
What are the practical strategies for implementation in the region of primary complaint?
• Should not be ignored
• Should be examined initially
• Treat as indicated in accordance with current best evidence
• Screen regions directly above and below the area of primary complaint within the first two visits
• In cases of recalcitrant and persistent symptoms, consider that symptoms may
be due to associated functional limitations and impairments in more distant body regions as well as other body systems
• Work to prioritize intervening in these regions during the course of care
What does the patient response based model do?
- Considers pain reproduction and reduction occurring with positioning or movement as
determined in assessment - Patient response during and after intervention guides selection and progression treatment parameters (i.e. direction, amplitude, force, speed)
- Does not necessarily rely upon specific biomechanical model for diagnostic assessment, rather it is the sign and symptoms based model
What is the 1st step in implementing the patient response-based model and what does it entail?
Assess
• Identify signs and symptoms
deemed to be comparable to the patient’s complaints and relevant to patient’s outcomes (aka. patient response triggers or asterisk signs)
Subjective asterisk signs include ___
Subjective asterisk signs include signs and symptoms identified by the patient through the course of an interview
Objective asterisk signs include those ___
Objective asterisk signs include those identified through physical examination, including physical signs relevant to the complaint of a patient
What is the 2nd step in implementing the patient response-based model and what does it entail?
Treat
- Provide intervention based on best available evidence, and influenced significantly by judgements provided regarding presentation, including the SINSS as determined by the PT
- Interventions should be responsive to patient’s values and abilities
What is the 3rd step in implementing the patient response-based model and what does it entail?
Reassess
• Reassess to determine if any changes can be associated with administered intervention
• Consider previously designated asterisk signs as
comparable to complaints and relevant to function
• Consider temporal nature of changes
- Within-session changes
- Between-session changes
• Additional treatment parameters adjusted
according to response
What is the 4th step in implementing the patient response-based model and what does it entail?
Instruct
• Instruct patient in activities to promote maintenance of gains attained through manual therapy
What are the benefits of the patient response based model?
• Adaptability to individual patients and symptoms even as
presentation changes throughout treatment
• Facilitates specificity of treatment
• Not overly reliant upon particular diagnostic or biomechanical models
• Respects diagnosis, but guides treatment decision making based upon impairment-based findings
• Small, but growing body of evidence to support use of model in clinical reasoning
• Relatively intuitive and easy to learn
• Provides framework for integrating evidence into practice
What are the limitations of the patient response based model?
• Time and energy intensive
• Initially assumes relevance of all findings and that each
finding has potential to influence decision making and
progress
• Within-session or even between-session improvements do not always equate to long-term improvements
• Requires concerted and clear communication between
clinicians and patients
• No utterly compelling evidence to support use of model as compared to others
What are the contraindications of manual therapy?
• Multi-level nerve root pathology • Worsening neurological function • Unremitting, severe, nonmechanical pain • Unremitting night pain (preventing patient from falling asleep) • Relevant recent trauma • Upper motor neuron lesions • Spinal cord damage
What are the precautions to manual therapy?
• Local infection • Inflammatory disease • Active cancer • History of cancer • Long-term steroid use • Osteoporosis • Systemically unwell • Hypermobility syndromes • Connective tissue disease • Recent manipulation whether by another health professional or lay individual
What are some key questions to ask before the PT can decide whether or not to use certain manual therapy techniques?
- Does the PT have the requisite arm length to administer the technique
- Is there a significant mismatch between the weight of the PT and the patient?
What are the various supine thoracic manipulation techniques?
- Scoop
- Active flexion
- Scoop with a bolster
- Active flexion with bolster
- Reach across table
What is the grade I (non-thrust) in the grading mobilization/manipulation technique?
• Small-amplitude movement near the starting position of available range
What is the grade II (non-thrust) in the grading mobilization/manipulation technique?
• Large-amplitude movement that carries well into available range occupying any part of range that is free from resistance
What is the grade III (non-thrust) in the grading mobilization/manipulation technique?
• Large-amplitude movement that moves into resistance (i.e. between R1 and R2)
What is the grade IV (non-thrust) in the grading mobilization/manipulation technique?
• Small-amplitude movement maintained within resistance (i.e. Between R1 and R2)
What is the grade V (thrust) in the grading mobilization/manipulation technique?
• Low-amplitude, high-velocity movement commonly, but not always, performed at end of available range
What does R1 in the grading mobilization/manipulation technique mean?
R1 = Perceived first resistance from target tissues
What does R2 in the grading mobilization/manipulation technique mean?
R2 = Perceived end range
resistance from target tissues
What does L in the grading mobilization/manipulation technique mean?
L = Absolute limits of normal available range
What are the things the PT should do when selecting a grade of mobilization/ manipulation technique?
- Remain disciplined in consideration of all three pillars of evidence-based
practice paradigm - Consider patient’s overall presentation with respect to severity, irritability, and
nature of their symptoms - Proceed into manual assessment and intervention with clear intent
What are some more things the PT should do when selecting a grade of mobilization/ manipulation technique?
- Continually monitor patient’s responses and attempt to
associate this with what is being perceived through
manual contact upon patient - Consider relationship of movement to pain and tissue
resistance to clarify and correlate associations between the occurrence of symptoms and perceived tissue resistance, which can inform grading selection - Modify technique based upon continual assessment of
patient’s signs and symptoms in conjunction with changes in tissue resistance that may be occurring as perceived through manual contacts
What are some key factors to consider for selecting a manual therapy technique for use for a patient?
• Reflect upon current best evidence • Match technique selection and grading to the patient’s presentation, positional tolerance, and size • Consider your own size relative to the patient as well as your own skill level with particular techniques • Respect the values of the patient
