Week 9 (parts 1, 2 and 3) Flashcards
Part 1
Introduction to Mobilisation techniques
what is the evidence for Mobilisations
- There is no evidence it has a negative effect.
- There is no evidence it increases patients reliance on passive treatment.
- Spinal mobilisations had a similar or better outcomes compared to NSAIDS with fewer side effects, (Bronfort et al, 2004)
- PA mobilisations can reduce spinal stiffness and pain (Shum et al, 2013)
- There is some evidence spinal mobilisations reduce pain and increase function in acute LBP, neck pain and persistent LBP (Bronfort et al, 2004)
- Spinal mobilisation can cause a normalisation of muscle function, but whether this is associated with symptom reduction or not and the underlying mechanisms of action remained unclear Lascurain-Aguirrebeña et al., 2016.
- Evidence that is has short term effects on pain and joint mobility in patients with knee OA and following ankle inversion injuries.
what is the evidence against mobilisations
- No difference has been demonstrated between manual therapy and other interventions for persistent LBP, (Rubinstein et al, 2013)
- Mobilisations had a minimal effect in reducing pain and no effect in reducing disability in patient with persistent LBP (Coulter et al, 2018)
- It is a passive treatment which some clinician feel increases patient reliance on services (though there is no evidence to this effect).
- There is some evidence that minor or major adverse effects can occur after manual therapy, (Carnes et al, 2009)
what should you consider about the evidence surrounding mobilisations
- Patient expectations of treatment effectiveness is one of the largest predictors of outcome for both conservative and surgical management.
- The best evidence is in patients who are ‘pain adaptive’ ie have clear aggravating and easing factors and who can change their pain with movement or repetitive movements.
- It is most effective when used to modulate pain in conjunction with other modalities eg rehabilitation exercises and cognitive behavioural therapy.
- It can be a useful tool in pain management if used in the right patients for 2-4 sessions while the patients build on their independent rehabilitation, load management and capacity.
what are the contraindications to joint mobilisations
- Fractures
- Gross instability
- Metastases or other bone disease
- Joint infections / inflammation
- Spondylolisthesis
- Osteoporosis
- Serious spinal pathology eg CES
- Neurological disease or problems
- CRPS
what are the precautions for mobilisations
- Pregnancy
- Severe pain
- History of trauma
- RA and other rheumatological conditions
what are the aims of mobilisations
- Reduce pain
- Increase range of movement
- Improve function
o The clinical effectiveness of manual therapy is often attributed to biomechanical mechanism (biomechanical model).
o The neurophysiological model suggests it is the neurophysiological effects of MT originating from peripheral mechanisms, spinal cord mechanisms, and/or supraspinal mechanisms which are responsible for its effect.
o The limitation of the current literature is the failure to account for non-specific mechanisms, such as placebo, which are associated with MT in the treatment of musculoskeletal pain.
o Therefor further studies would be beneficial, (Gibson 2013).
what is the Maitland Grading system
There is no evidence that there is any difference between the grades in terms of pain-relieving effect, but we need something for documentation and clinical reasoning.
Grade I – small amplitude movement at the beginning of the available range of movement
Grade II – large amplitude movement at within the available range of movement
Grade III – large amplitude movement that moves into stiffness or muscle spasm
Grade IV – small amplitude movement stretching into stiffness or muscle spasm
o Lower grades (I + II) are used to reduce pain and irritability (use VAS + SIN scores)
o Higher grades(III + IV) are used to stretch the joint capsule and passive tissues which support and stabilise the joint so increase range of movement
Direction:
* Anterior-posterior – AP
* Posterior-anterior – PA
* Eg Femoral PA = Tibial AP
* Caudad (towards feet)
* Cephalad (towards head)
* Distractions
* Pause and work what the following mobilisations would look like and what other mobilisations would have the same effect:
o Tibia AP at the knee
o Tibial PA at the ankle
how do you decide which way to mobilise
Concave/ Convex rule
* Previously it was believed that you needed to mobilise in a specific direction to increase a specific range of movement.
* The direction was based on the concave-convex rule which stated that:
o When the concave bone moves; it moves in the same direction as the joint glide.
o When a convex bone moves, the glide is in the opposite direction to the bone movement.
* Theoretically, to increase knee flexion you would perform an AP glide on the tibia or a PA glide on the femur.
* However, it has been shown that direction doesn’t really matter, so don’t worry!
how do you document mobilisations
- Joint / bone / spinal level
- Grades - 1-4, (or I, II, III, IV)
- Duration / number of mobilisations (2 minutes, 5 minutes, 30 x 5 etc)
- Direction – AP, PA, caudad, cephalad, distraction
- Spinal -
- lines indicating direction of mobilisation
o G3 AP mobilisation on tibia, 5 mins // inc DF Knee to wall 8cm (prev 6cm)
o G2 PA mobilisation central L4, 30 x 6 // inc Lx flexion, fingers to infrapatella (prev suprapatellar)
o G2 L5, 4 mins // inc Lx ext, full P free.
part 2
Joint Mobilisations Practical
what should you consider when using Mobilisations in treatment sessions
Identify a problem which would benefit from mobilisations
Gain INFORMED CONSENT
Assess and document initial objective measure
Treat using the appropriate mobilisations considering the aims, grade, joint / bone, direction and duration.
Retest the objective measure
Give advice and exercises to maintain the improvements you have made
what are some Ankle mobilisations
- Tibia + Fibula Anterior - posterior (dorsiflexion)
- Calcaneus + Talus Posterior – anterior (plantarflexion)
- Lateral to medial glide (inversion)
- Medial to lateral glide (eversion)
what are some Knee Mobilisations
- Fibula head Anterior – posterior
- Patella laterally, medially, Inferiorly (flexion), Superiorly (extension)
- Tibial PCL test Anterior – posterior (extension)
- Tibial ACL test Posterior – anterior (knee bent + extended) (flexion)
- Femur Anterior – posterior (extension)
- Femur Posterior – anterior (flexion)
what are some Hip mobilisations
- Lateral glide of Femur (using hands)
- Lateral glide of Femur (using belt) – can move hip into flexion, adduction, abduction, internal rotation, external rotation while laterally gliding with seatbelt
- Use seatbelt attached to ankle to pull/ extend hip out of socket slightly
what are some Spinal mobilisations
- Find L4 (level with Iliac crests), press down with pisiform
- Press down laterally to spinous process
- Move Spinous process laterally using thumbs
part 3
manual therapy and soft tissue techniques
what does normal function require from the soft tissues
It requires the soft tissues to be in a normal state
– Skin
– Connective tissues (ligament, capsule, retinaculum, fascia)
– Muscles (musculotendinous junction, tendon, muscle belly, osseous connections)
– Nerve
So how do we manage dysfunction with manual therapy?
what are some joint based techniques
– Mobilisation (defined as low-velocity techniques that can be performed in various parts of the available range based on the desired effect).
– Manipulation (defined as a small-amplitude, high velocity thrust technique – a rapid movement over which the patient has no control).
what are some soft-tissue based techniques
– Massage
– Muscle Energy Techniques (MET) and myofascial release
– Stretching and Proprioceptive Neuromuscular Facilitation (PNF)
– Specific soft tissue mobilisations
– Frictions
– Trigger points
Nerve based techniques – neurodynamics
what is amplitude
in physics is the maximum extent of a vibration or oscillation, measured from the position of equilibrium.
what is velocity
quickness of motion – speed; rapidity of movement.
Therefore, mobilisation is slower that manipulation; hence, patient can be taught to safely self-mobilise with movement!
what is MET (Muscle Energy Technique)
Muscle Energy Technique (MET), a manual therapy technique, uses a patient’s muscle contractions to relax and lengthen muscles, improve joint mobility, and reduce pain, by applying resistance to isometric contractions.
Here’s a more detailed explanation:
* What it is:
* MET is a form of manual therapy developed by Fred Mitchell, Sr., DO, in 1948. It’s based on the principle that contracting a muscle in a specific direction, while the therapist provides counterforce, can relax and lengthen the muscle and improve joint mobility.
what is PNF
Proprioceptive Neuromuscular Facilitation is a stretching technique that improves flexibility and range of motion by combining stretching with muscle contraction and relaxation, often used in rehabilitation and athletic training.
Here’s a more detailed explanation:
* What it is:
* PNF stretching involves a series of controlled stretches, followed by isometric contractions (muscle contractions without movement) and then a further stretch into a new range of motion.
* How it works:
* The muscle contractions and relaxations stimulate the body’s proprioceptors (sensory receptors that provide information about body position and movement), which can lead to greater flexibility gains.
what do we need to know to facilitate management using manual therapy
Basic science of soft tissues (incl. muscle and nerve)
– Tissue biology, composition and characteristics
– Tissue biomechanics – stress/strain curve
– Tissue homeostasis – responses to physical stimuli
Soft tissue healing
– Staging
– Muscle contraction
– Neural control of movement
Physiological changes associated with
– Injury (overuse, overload, trauma) or pathology
– Immobilisation or detraining
– Exercise (strength, power, endurance, proprioception and coordination)
– Altered motor control, Fatigue
– Age
Indications and contraindications
what is the effect of touch in manual therapy
Can be expressive as well as instrumental – match to the patient’s condition
Remember touch is bi-directional so
– Make sure it is appropriate to the condition
– That you make the objectives very clear – prevent misinterpretation
– Be aware of the feedback response you get – this can be very subtle but important
– Don’t communicate negative messages
Analgesic touch – able to modulate pain by biasing signal detection, buffering pain intensity and quality of sensation (Mancini et al. 2014, Pain relief by touch: A quantitative approach)
Affective touch – communicate sympathy, comfort, support, reassurance and elicit positive emotions (Hertenstein et al., 2009) and reduce negative feelings
Somatoperceptual – able to locate pain and tactile stimuli (Puentedura and Flynn, 2016)
what therapeutic effects do they have
Assist two body processes
Repair processes – stress for better repair, influence fluid flow and blood perfusion, and tissue length adaptation
Adaptation process – assisting adaptive repair for physical demands vs maladaptive
Crucial to match dosage, progression, regression to stage of healing and condition
Mechanical – Oscillatory, active movement and stretches invoke biomechanical and tissue adaptation changes
Autonomic – skin temperature, cortisol levels
Endocrine – release of endorphins
Neurophysiological – pain modulation through Aß on A∂ and C pathways, proprioception and motor adaptation
Affective – behaviour, cognition, emotions and mood through opioids and dopaminergic pathways, deactivation of stressful responses
Non-specific responses – Placebo
what techniques can we use
Massage
Muscle energy techniques
Myofascial release
Stretching
PNF
Specific soft tissue mobilisations
Transverse frictions
Trigger points
what questions should you ask yourself when making decisions about a patients needs
Am I?
– Aiming to support repair processes by improving flow?
– Aiming to improve tissue extensibility?
– Aiming to improve length?
– Aiming to reduce pain?
– Aiming to improve neuromuscular activity?
– Aiming to stimulate proprioception?
– Aiming to increase body awareness and postural guidance?
Note, it is not a recipe
what are some other decisions you will need to make as the physio
Timing – what and when?
When is it inappropriate – precautions and contraindications?
What psychological support does the patient need?
Balancing influencing pain, utilising the potential for therapeutic changes and quality of repair
Influencing tissue strength for mechanical demands and not exceeding tissue tensile strength
Importance of joint motion
Movement vs. immobility….where does immobilisation come into this?
Think about you, your capabilities and positioning
what are the implications for the physio
Helps you locate symptoms
Helps you communicate kindness, empathy, reception, firmness, support, comfort, reassurance
Helps you identify those who are likely to respond and gain increased acceptance and compliance
Helps you make use of the appropriate physical properties to invoke biomechanical and physical change
Helps you reduce pain
Cueing – helps you guide movement and activity to be performed correctly
what is the difference between critical thinking and critical appraisal
Whereas Critical Thinking relates to the general process of decision making that is used all the time in clinical practice, Critical Appraisal relates to a specifically applied process.
Critical Appraisal is being systematic in judging the merits and usefulness of research so that your decision-making is better informed.
Why should I do it? – so that the information you use to underpin your practice is high quality and reliable!
how do you critically appraise
Looking at the research to see what it was about and why was it done? Does it set the scene?
What was the type of study and was it appropriate?
– Quantitative research – all about numbers
– Qualitative research – going beyond numbers to explore the patient’s experience
– Systematic/meta-analyses/non-systematic reviews
– Trials and diagnostics
– Economic analyses
– Hierarchy of evidence
– Was the methods used appropriate
Are the results valid?
What is the value of these results? How do I apply them to what I do?
A simple framework for critical appraisal:
Identify the literature you think is relevant – Look at the context of each paper and ask yourself : Why was the study done? Is the research question relevant to me?
The next step - what are the good points and flaws
– Type of study – Is the method right to answer the research?
– Is the group or patients studied representative?
– Is there a statement of what they expected to find?
– Does it eliminate bias?
– (See Trisha Greenhalgh ‘How to read a paper’)
– Drawing your conclusion on the value of results
– Are the results significant enough to justify the conclusions?
– Are they plausible and believable?
– Is the evidence and argument supplied coherent, relevant and compelling?
– What do I think about the quality of the research?
What does it mean for me? – How can these results be applied to my practice?
what is criticality
Criticality is about using and questioning information rather than simply absorbing and then describing it.
It is about having that critical thinking/analytical approach and applying it specifically.
Then thinking about – What you have learnt and understood within this research picture/context and being able to understand the links, relationships, strengths of your thoughts and the weaknesses.
Then it is being able to articulate that!
Practical application of a critical appraisal:
You have 2 papers:
– Hariharasudhan and Balamurugan (2015) Effectiveness of muscle energy technique and Mulligan’s movement
– Jurecka et al., (2021) Evaluating the effectiveness of soft tissue therapy in the treatment of disorders and postoperative conditions of the knee joint
In your groups, review these papers.
Use the Critical Appraisal of Research doc (see canvas) for guidance.
We will discuss what you have produced!!!
