EVIDENCE-BASED MANUAL THERAPY AND SELF-CARE TECHNIQUES Utilizing - PowerPoint PPT Presentation

Neurophysiological Effects - Central Mechanisms   in pro-inflammatory cytokines after thoracic manipulation suggests down-regulation of inflammatory-type responses (Teodorczyk-Injeyan 2006)  Sympathetic nervous system excitatory response ฀  skin conductance/sweat and vasoconstriction from mechanical stimulus at cervical or thoracic spine, associated with immediate  in pain and mechanosensitivity, and  ROM during ULNTs (Chu 2014)  Increased muscle strength (Keller 2000; Cleland 2004, Libeler 2001, Suter & McMorland 2002) 32

Neurophysiological Effects - Central Mechanisms   dorsal horn sensitization and  afferent discharge = immediate  in pain (George 2006; Sterling 2001; Maduro de Camargo 2011; Mohammadian 2004)  Alters muscle tone via α motor neuron pool activity (Sterling 2001; Dishman 2002; Dishman 2002; Fryer 2012)  Immediate change in functional connectivity between brain regions that process and modulate pain (Gay 2014)  Effects on the descending pain inhibitory system (DPIS) discussed in pain science research 33

Psychophysiological Effects  Placebo is a psychobiological phenomenon occurring in the brain  Higher expectation/beliefs for treatments = significantly greater function/less disability (Kalauokalani 2001; Bishop 2013)  The “pop” from a manipulation and laying-on of skilled hands creates a psychological event  Not the reason we use manual therapy, but it has an effect 34

Mechanisms Summary  Decreases pain ฀ May be short-term immediate relief  Reduces muscle tone  Increases motion  Improves sensorimotor integration  Improves motor control 35

When is it Appropriate to Use Mobilization and Manipulation? 36

Indications for Joint Mobilization/Manipulation  In the presence of joint dysfunction  Neurophysiological effects for pain relief  Lack of contraindications 37

Absolute Contraindications (Dunning)  Vascular  Coronary artery disease; aortic aneurysm; severe hemophilia; vertebral artery disease  Bone  Tumor; TB infection; metabolic disease; congenital dysplasias; long-term corticosteroid use; inflammatory disease (RA); fracture; ligamentous (upper cervical instability)  Neurological  Cauda equina; cervical myelopathy 38

Absolute Contraindications (Dunning)  Excessive or extreme pain  Lack of a clinical diagnosis  Lack of patient consent 39

Absolute Contraindications (Kroon and Kruchowsky)  Relative to skill and experience  Unremitting, severe non-mechanical pain  Unremitting night pain (preventing patient from falling asleep)  Worsening neurological function  Empty end-feel and severe multi-directional spasm, which can be the result of various serious pathological findings  Post-surgical 40

Relative Contraindications (Dunning)  Disc herniation or prolapse  HNP present in 49-63% of individuals that have never had a significant bout of LBP  Pregnancy  Do not thrust between 12th-16th weeks (3rd and 4th month) of pregnancy, coincides with risk of miscarriage  HVLAT has never been shown to cause a miscarriage 41

Relative Contraindications (Dunning)  Osteoporosis, rheumatoid arthritis  Spondylolisthesis  Avoid extension  Advanced DJD, spondylosis 42

Precautions for Manipulation (Kroon and Kruchowsky)  Hunch/feel  History of neoplastic disease: risk of recurrence  Patient unable to relax  When you sense that the joint will not “give”  Adverse reactions to previous manual therapy  Physique  Children  When spinal movements or palpation reproduces distal symptoms  Pain with psychological overlay 43

Manipulation Guidelines  Manipulation is a treatment option, an intervention that we clinicians (may) have the authority and privilege to use ฀ Beneficial for some – some of the time – not for all ฀ May be part of an overall plan ฀ Use a multimodal approach ฀ Not a stand alone treatment or philosophy of care  Do so only after informed, planned, and individualized assessment 44

General Rules for Joint Manipulation  Patient relaxed  Perform in resting position of joint – never mobilize/manip in close-packed position of joint  Use good body mechanics  Visualize joint surfaces/mechanics  Techniques must suit body type of patient/therapist or be modified  Use the minimal force needed  Speed is key! 45

Post-Manual Therapy Treatment  The lasting effect of a single session of HVLA thrust ranged from no effect up to a maximum of 5 hours (Coronado 2010)  Manipulation works fast ฀ Changes in sensory processing (reset) gives us a window into the nervous system and a chance to alter motor control with the ultimate goal of a better expression of movement ฀ Tells the nervous system that movement is OK 46

Post-Manual Therapy Treatment  Re-establishing and then maintaining normal movement is critical  Clinical and home exercises should target the nervous system to further modulate sensory input and motor control to regain normal movement patterns 47

GET THEM MOVING… AND KEEP THEM MOVING 48

REGIONAL INTERDEPENDENCE “A Musculoskeletal Examination Model Whose Time Has Come” 49

Regional Interdependence (RI) “RI 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.” (Wainner 2007) Likely includes musculoskeletal factors, as well as a  neurophysiological component (Bialosky 2008) UPDATED “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).” (Sueki 2013) 50

Regional Interdependence (RI)  RI represents the musculoskeletal manifestation of a larger interdependent process by which other systems may be involved in eliciting these MSK changes (Sueki 2013) 51

Regional Interdependence (RI) The redefined concept from 2013 (Sueki) proposes:  Response(s) to a disorder or condition and the associated clinical outcome(s) are not limited to local and adjacent regions of the body but can involve a neuromusculoskeletal response that may be more widespread.  Multiple systems respond to impairment and may influence the function of the neuromusculo-skeletal system and associated symptoms. 52

RI Examples in Literature (Sueki 2013) UPPER QUARTER LOWER QUARTER  Thoracic spine – Cervical  Hip – Lumbar spine spine  Hip – Knee  Thoracic spine –  Knee – Lumbar spine Shoulder  Foot/ankle – Lumbar  Thoracic spine – Upper spine extremity  Ankle - Knee  Cervical spine – Upper extremity 53

TREATMENT OF THE NECK, SHOULDER, AND THORACIC SPINE 54

Thoracic Spine Anatomy Review  Thoracic vertebrae shorter anteriorly than posteriorly ฀ This combined with wedge shape of discs creates thoracic kyphosis  Increase in size from superior to inferior as the spine transitions from the smaller cervical vertebrae to the larger lumbar vertebrae  Spinal canal is more narrow, particularly from T4-T9 ฀ Tension point at T6 – vulnerable site in nervous system 55

Thoracic Vertebrae Characteristics  T2-T9 are typical thoracic vertebrae ฀ Facets angled at 60 degrees in the transverse plane ฀ Allows for lateral flexion and rotation ฀ Spinous processes angle inferiorly  T1 shares similarities with cervical vertebrae ฀ Uncinate processes ฀ Spinous process larger and more horizontal  T12 shares similarities with lumbar vertebrae ฀ Inferior articular processes oriented in sagittal plane like lumbar facets, restricting rotation 56

Lateral View of Thoracic Vertebra johnthebodyman.com 57

Spinal Facet Orientation 58

Thoracic Facet Orientation  Superior articular facets ฀ Face posterior, lateral, and superior  Inferior articular facets ฀ Face anterior, medial, and inferior Mulliganconcept.com 59

Thoracic Arthrokinematics  Flexion ฀ Inferior facets of superior vertebrae glide up and tilt forward  Extension ฀ Inferior facets of superior vertebrae glide down and tilt backwards  Right sidebending ฀ Inferior facet of superior vertebrae on the right glides down and tilts backwards ฀ Inferior facet on the left glides up and tilts forward  Right rotation ฀ Inferior facet of the superior vertebrae on the right glides down and tilts backwards ฀ Inferior facet on the left glides up and tilts forward 60

Shoulder Anatomy Review  Glenohumeral joint  Acromioclavicular joint  Sternoclavicular joint  Scapulothoracic “joint” 61

Glenohumeral Joint Anatomy  Convex humeral head on concave glenoid fossa ฀ Humeral head much larger surface than glenoid fossa  Think golf ball on a tee  Glenoid fossa deepened by the labrum ฀ Glenoid fossa angled to face anteriorly approx 30 o  Joint capsule ฀ Attached to the circumference of the labrum and the glenoid fossa ฀ Axillary recess allows for abduction to occur ฀ Glenohumeral and coracohumeral ligaments blend into the capsule 62

Glenohumeral Joint Anatomy adamdziemianko.blogspot.com 63 stjohn-clarkptc.com

Glenohumeral Arthrokinematics  Flexion ฀ Rotational spin with posterolateral glide of the humeral head  Abduction ฀ Inferior glide of the humeral head  External rotation ฀ Anteromedial glide of the humeral head  Internal rotation ฀ Posterolateral glide of the humeral head 64

Regional Interdependence Implications Involving the Thoracic Spine 65

Thoracic Spine Treatment for Cervical Pain Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial (Cleland 2005)  36 subjects with mechanical neck pain  Randomized into 2 groups: thoracic spine manipulation or placebo manipulation  Outcome measure was immediate (short-term) change in VAS pain scale  Thoracic spine manipulation group demonstrated clinically significant immediate improvements in perceived level of neck pain compared to placebo manipulation group 66

Thoracic Spine Treatment for Cervical Pain Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial (González-Iglesias 2009)  45 participants with acute mechanical neck pain <1 month  Control group – electro/thermal therapy over 5 visits  Experimental group – electro/thermal + thoracic spine thrust manipulation added at 3 of 5 visits  Outcome measures included pain rating, cervical range of motion, and disability rating (NPQ)  Experimental group experienced greater improvements in pain, cervical range of motion, and disability at 5 th session and at 2- week follow-up  Pain reduction in experimental group continued at 1-month follow-up 67

Thoracic Spine Treatment for Cervical Pain Short-term combined effects of thoracic spine thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized clinical trial ( Masaracchio 2013)  64 participants with mechanical neck pain <3 months  Control group – 2 sessions of c-spine Gr. III mobilizations and HEP  Experimental group – 2 sessions of c-spine Gr. III mobilizations, HEP, and 2 thrust manipulations each to upper and middle thoracic spine  Outcomes measures included NPRS, NDI, and GROC  Experimental group demonstrated better overall short-term (<1 week) outcomes in NPRS, NDI, and GROC than control group 68

Thoracic Spine Treatment for Shoulder Pain The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome (Boyles 2009)  56 patients with shoulder impingement syndrome in a one group pre-test/post-test study  Group received thoracic spine manipulation after shoulder examination  Outcome measures included NPRS, SPADI, and GROC  At 48-hour follow-up, decrease in NPRS during various shoulder impingement tests was statistically significant  Also significant reduction in SPADI and GROC 69

Thoracic Spine Treatment for Shoulder Pain The immediate effects of thoracic spine and rib manipulation on patients with primary complaints of shoulder pain (Strunce 2009)  21 subjects with primary c/o shoulder pain using test/re-rest design  Subjects received HVLA manipulation to upper thoracic spine and/or ribs based on impairments found during examination  Primary outcome measures were pain VAS and shoulder AROM  Statistically and clinically important improvements for the entire group were demonstrated in post-treatment shoulder ROM measurements and VAS pain scores immediately following manual therapy ฀ One or more thoracic and/or rib impairments were identified in each subject, including CTJ restrictions in 71%, upper thoracic restrictions in 100%, and unilateral rib restrictions in 79% 70

Thoracic Spine Treatment for Shoulder Pain Effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy (Muth 2012)  30 subjects with signs of RC tendinopathy received thoracic spine manipulation  Pre- and post-manipulation measurements of scapular kinematics, scapular muscle activity, shoulder pain, and function (PSS and SPAM-DASH) were assessed  No significant changes were observed in scapular range of motion or kinematics; did observe small but significant increase in middle trapezius muscle activity, but no other muscles  Subjects did demonstrate decreased pain with various shoulder impingement tests, decreased pain with shoulder flexion, and improved shoulder function  Conclusion: immediate improvements in shoulder pain and function post-thoracic manipulation are not likely explained by alterations in scapular kinematics or shoulder muscle activity ฀ Outcomes support the likelihood of other neurophysiological processes at play 71

Other Thoracic Spine Articles of Interest  Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain (Berglund 2008)  Joint manipulation in the management of lateral epicondylalgia: a clinical commentary (Vicenzino 2005)  The effectiveness of thoracic spine manipulation for the management of musculoskeletal conditions: a systematic review and meta-analysis of randomized clinical trials (Walser 2009)  Regional interdependence and manual therapy directed at the thoracic spine (McDevitt 2015) 72

Thoracic Spine and Shoulder Manual Therapy Interventions 73

Common Reasons for Treating the Thoracic Spine  Pain(!) ฀ Thoracic, cervical, or shoulder (and maybe even elbow)  Limited range of motion ฀ Thoracic, cervical, or shoulder  Shoulder impingement signs ฀ Pain and limited ROM combined, painful arc, etc.  Poor scapular muscle motor recruitment  Absence of contraindications 74

Supine Thoracic Manipulation Patient crosses arms across chest (arm towards PT goes  inferior), tightly to take up slack Roll patient towards PT  Flat hand with fingers facing patient’s head, spinous process  between thenar and hypothenar eminences, adduct arm to stay medial to scapula May also use a closed fist, with loose MCP flexion  Roll patient back over hand so they are flat; therapist’s mid-  section should be over patient’s elbows, head over opposite shoulder Flex spine to the level to be manipulated with the other arm  across the patient’s arms, then place your trunk on top to hold them in place Provide compression via body contact, but keep chest up –  may help to look out in front of you instead of down Short, quick thrust anterior to posterior  75

Supine Thoracic Manipulation 76

Prone Thoracic Rotational Mobilization/Manipulation  Patient in prone, arms over side of table  Therapist stands on side to be mobilized  Hypothenar eminence of caudal hand on same side TP  Hypothenar eminence of cranial hand on opposite TP, but at same level  “Screw home” so fingers of cranial hand point caudally and fingers of caudal hand point cranially – not part of the mobilization  Mobilize caudal hand in cranial/anterior direction, and cranial hand in caudal/anterior direction  If performing manipulation, thrust towards end of patient exhalation 77

Prone Thoracic Rotational Mobilization/Manipulation 78

Glenohumeral Joint Inferior Glide  Patient in supine with shoulder in resting position (55 o abd, 30 o hor add)  PT stands at side of table facing pt, with caudal hand under upper arm and cranial hand on superior lateral border of humeral head  Use your arm and body to hold/support patient’s arm and facilitate relaxation  Use caudal hand to gently distract the joint  Use cranial hand to glide humerus inferiorly  Used to increase elevation of shoulder 79

Glenohumeral Joint Inferior Glide 80

Glenohumeral Joint Posterior Glide  Patient in supine with shoulder in resting position (55 o abd, 30 o hor add)  Can place towel under scapula to help stabilize  PT stands at side of table facing patient, with cranial hand on superior anterior aspect of humeral head, and caudal hand on medial side of arm  Use your arm and body to hold/support the patient’s arm and facilitate relaxation  Use both hands to gently distract the joint, then glide posteriorly  Used to increase internal rotation and flexion  Also used to help glenohumeral joint function in neutral position (in presence of anterior laxity or anterior humeral head position) 81

Glenohumeral Joint Posterior Glide 82

Thoracic Spine Exercise Interventions 83

Supine Longitudinal Thoracic Spine Self-Mob on Foam Roller  Foam roller running length of spine, supporting head and buttock  Knees bent to reduce strain on lumbar spine  Duration dependent on tolerance  Flex elbows to avoid median nerve irritation 84

Supine Shoulder Flexion with Dowel Rod on ½ Roller  Use ½ roller, pool noodle, etc.  Position roller so it is perpendicular to thoracic spine  Foam roller can be placed at most restricted level, but may have to start elsewhere  Encourage shoulder movement through tolerate range 85

Seated Thoracic Extension on Chair Using Dowel Rod  Similar to supine shoulder flexion, but now uses chair back as a fulcrum  May need pillow or roll for lumbar support  Encourage minimal cervical spine movement 86

Ball Walks on Wall with Thoracic Extension Emphasis  Alternative to wall climbs  Encourages increased thoracic extension as part of overhead movement  Can also utilize for retraining of scapular protractors and upward rotators 87

Other Thoracic/Shoulder Exercise Considerations  Scapular muscle motor control/strength ฀ Serratus anterior ฀ Lower trapezius ฀ Middle trapezius  Rotator cuff motor control/strength  Cervical deep neck flexor motor control/strength 88

TREATMENT OF THE LUMBAR SPINE, HIP, KNEE, AND ANKLE/FOOT 89

Lumbopelvic-Hip Complex 90 Strengthphysio.com

Lumbopelvic-Hip Complex  Refers to the biomechanical relationship between the low back and hips  Pelvis/SI joint interface  Multiple shared muscles ฀ Iliopsoas ฀ Quadratus lumborum ฀ Erector spinae ฀ Gluteus maximus ฀ Gluteus medius  Contraction of these muscles can affect motion at the spine, pelvis, and hips 91

Lumbar Spine Anatomy Review  Multiple muscle and ligament attachments  Articular processes  2 superior and 2 inferior to form the facet joints  Predominant motion is in the sagittal plane due to the orientation of the facet surfaces  Flexion and extension dominate movement availability  Sidebending somewhat limited  Rotation is the most limited (happens primarily at upper lumbar segments) 92

Lumbar Vertebrae uscspine.com 93

Lumbar Facet Joints  Formed by inferior articular process of the superior vertebra and the superior articular process of the inferior vertebra  Nearly 90 o orientation to the transverse plane  Principle guiding and restraining mechanism of the segment  Protect disc from excessive strain and keep the joint stable  Surrounded by a fibrous capsule ฀ Thick dorsally, reinforced by multifidus fibers ฀ Anteriorly replaced by the ligamentum flavum  Have intra-articular meniscoid structures that protect the joint and keep the joint surfaces lubricated during movement 94

Lumbar Facet Orientation  Superior articular facets ฀ Face medial and superior  Inferior articular facets ฀ Face lateral and anterior 95

Hip Anatomy Review  Ball and socket joint formed by femoral head and acetabulum ฀ Femoral head faces anterior, medial, and superior ฀ Acetabulum faces anterior, lateral, and inferior  Stability improved by the labrum, which deepens the socket ฀ Also allows for mobility by virtue of its elasticity 96 studyblue.com

Hip Anatomy Review  Joint capsule shaped like a cylindrical sleeve ฀ Inserts medially onto acetabular ring, transverse ligament, and peripheral surface of the labrum ฀ Inserts laterally into base of the femoral neck ฀ Strengthened anteriorly by fibers of the rectus femoris  Hip joint ligaments ฀ Ligamentum teres ฀ Iliofemoral ligament ฀ Pubofemoral ligament ฀ Ischiofemoral ligament 97

Hip Joint Arthrokinematics  Flexion ฀ Femoral head rolls anteriorly and glides posteriorly  Extension ฀ Femoral head rolls posteriorly and glides anteriorly  Abduction ฀ Femoral head glides inferiorly  Internal rotation ฀ Femoral head glides posteriorly  External rotation ฀ Femoral head glides anteriorly 98

Regional Interdependence Implications Involving the Lumbopelvic-Hip Complex and Lower Quarter 99

Hip-Spine Syndrome (Offierski 1983)  Concept of a biomechanical link between the hip joint and the lumbar spine  Specifically depicts the influence of a pathological hip joint on the alignment of the spine and subsequent muscle length and joint forces 100