Purpose

To consolidate and expand your knowledge and skills of Manual Therapy

Objectives

• Canadian Manual Therapy history

• Subjective examination

• Objective examination –lumbar, pelvis , hip,cervical , TMJ,

• Treatment approaches including mobilizations, exercise, education and manipulation

Definition of Manual Therapy

A comprehensive system of diagnosing and treating neuromusculoskeletal disorders involving specific skills, including assessment, mobilization, manipulation and education, in conjunction with exercise, to restore optimal motion, function and/or reduce pain.

MTSC Vision 2001

Clinical Reasoning

Hear See Feel

Biomedical Knowledge

Clinical Knowledge – knowledge, skill experience

Clinical Reasoning

• The process of drawing conclusions based upon known or presumed facts

• Development of an accurate diagnosis and prognosis

Hypothesis Generation

• Data collection• Interpretation of information• Cross-examination• Contributing factors• Hypothesis modification• Treatment• Reassessment• Prognosis

Beginner

• Systematic approach

• Gather as much information until diagnosis emerges

• Check list may be helpful

• Takes longer to recognize clinical patternsLevel 1 pg 4

Novice

• Repertoire of clinical patterns

• Abandon checklist

• Lack experience to identify all clinical patterns

• Often tempted to make assumption

Expert

• Need a superior knowledge base from which to generate a high quality hypothesis

• Clinical patterns

What qualities define a clinical specialist?

• content knowledge

• practical knowledge

• technical skill

• application of general principles or theory

• critical analysis Mildonis et al, JOSPT,

1999

Expert

• Intense focused connection with patient, verbal and non

• Use clinical patterns and inductive reasoning to develop a diagnosis

• Comfortable with the uncertainty of not knowing the immediate diagnosis

Expert

• Management becomes more efficient and effective

• “ seeing” the clinical pattern

• Allows PT to focus on 1 or 2 primary issues

• Recognize what features are most significant and in need of attention

Former Paradigm

• Unsystematic observations OK

• Knowing basics OK

• Common sense enough

• Clinical experience enough

The Danger of Relying on Experience Alone

“making the same mistakes with increasing confidence over an impressive number of years.” M. O’Donnell. A Skeptic's Medical Dictionary

Is that 25-years of experience or 1-year of experience repeated 25-times?

New Paradigm

• Intuition- misleading

• Rationale for treatment and discharge may be incorrect

• Understanding rules to interpret the literature is necessary

Why Evidence- based Practice

• 30,000 biomedical journal articles per year with a 7% increase each year

• There are over 3,200 physiotherapy articles published per year

• To keep up to date, a clinician would need to read approximately 10 articles per day

• If 2 articles are read per day, after 1 year a clinician would be approximately 4 years behind

Consequences of Not Keeping Up-To-Date

• Lag in optimal practice behaviors

• Clinical practice is opinion driven

• Patients may be denied best care

• Patients may selectively know more than clinicians

Evidence-based Practice

“the integration of best research evidence with clinical expertise and patient values”

D.L. Sackett et al, 2000

Definition of Manual Therapy

A comprehensive system of diagnosing and treating neuromusculoskeletal disorders involving specific skills, including assessment, mobilization, manipulation and education, in conjunction with exercise, to restore optimal motion, function and/or reduce pain.

MTSC Vision 2001

Aim of Manual Therapy

• Pain relief

• Restoration or improvement of function

• Restoration of an acceptable predetermined level of physical lifestyle

• Prevention of further episodes

• Education, communication , documentation

Homeostasis

Restoration of normal repair processes facilitated and pain is alleviated

Diagnosis

• Is physical treatment a treatment of choice?

• If so, what type of physical treatment should be used?

• Manual Therapy must be based upon diagnostics rather than signs and symptoms

Scope of Manual Therapy

• Mobilization, Traction, Manipulation

• Muscle Energy, PNF

• Dynamic soft tissue release

• Muscles rebalancing, muscles co-contraction

• Stabilization, Exercise Therapy

• Functional Rehabilitation

Cyriax

• Principle – “ search for physical signs , positive and negative and their interpretation”

• Selective tissue tension testing

• Contractile • Inert

Subjective Assessment

Why is it SO Important?

List the negatives of a history from the patient’s point of view

List the positives from a patient’s point of view

What are your goals when starting a subjective assessment?

The Art of Listening

“ We are in danger of overlooking the simple psychological potency of giving patients a good hearing, listening attentively, giving them the benefit of the doubt , handling them with confidence and skill and simply striving to do our shop floor clinical work with effectiveness. Failure to properly examine the patient may lead to unnecessary mischief.”

……..Grieve 1991

Listening is an ART:

• That is where it differs from hearing• Hearing is passive• Listening is active• Hearing is involuntary• Listening demands attention• Hearing is natural• Listening is an acquired discipline

( the Age ’82)

Use our communication skill to help patient understand……

• What manual therapy is all about• What it can do for them• What the treatment will entail• What are their options• What part they play in recovery and treatment• What part they play to maintain their acquired

healthy state A Moore + G Jull

Manual Therapy 2001

Assessment

• Subjective History

• Objective - observation- active – passive- resisted

• Interpretation of Evaluation– Capsular pattern– Resisted findings

Treatment

• Transverse frictions

• Stretch

• Manipulation

• Injections

Lower Quadrant Scan

• Rule out serious pathology

• Isolate area of dysfunction

• Identify others areas in the body that may need attention

Observation

• Postural type

• Gross deformities

• Gait

Clearing Tests

• Squat

• Twist

• Walk (on heels and toes)

Active movements – OP if not painful

• Lumbar Spine flexion, extension, side flexion and rotation

• Hip flexion, extension, rotation, abduction

• Knee flexion, extension

• Ankle dorsi, plantar, inversion, eversion

Myotomes• L1-2

hip flexion• L3

Knee extension• L4

Ankle dorsiflexion• L5

Gt toe extension, hip abduction• S1

PF ankle, eversion , knee flexion• S2

Hip extension

Dermatomes

• Light touch – cotton ball, kleenex

• Sharp- dull – acupuncture needle, paper clip

L5 L4

S2

Sensory Testing

Lower QuadrantHoppenfeld’76

Reflexes

Quad - L3

Hamstrings - L5

Achilles - S1

Pathological Reflexes

Clonus

Babinski

Neg

Pos

Dural

• SLR

• Slump

• Prone knee bend

Articular

• SI stress test – anterior , posterior

• PA’s lumbar spine – spring tests

Perform a lower quadrant scan

Kaltenborn

• Subjective

• Objective

– Cyriax

– Plus accessory movements

Treatment

• Hyper

• Hypo

• Restore normal glide

• Arthrokinematics – decrease capsular tightness

Maitland Concept

• Open mind

• Mental agility

• Mental discipline

• Logical

• Methodical process of assessing cause and effect

Link with

Assessment

Subjective

• Provides guidelines

• Pain patterns

Objective• Priorize assessment• Active, passive, pain,

resistance• Accessory

movements• Salient signs• Quadrants• Movement diagrams

Treatment

• Interpretation of evaluation

• Grading

• Techniques

• Reassess

Maitland

“ When trying to improve the quality of the sick joint’s movement by a passive movement technique it is necessary to put your mind inside the joint area and involve yourself emotionally with what the joint is trying to tell you”

Grades of Movement

Demonstrate + explain use

• Grade 2 physiological flexion of the knee jt

• Flexion/adduction/MR grade 3 + hip joint

• Grade 4 + Plantar flexion MT /IP jt great toe

• Traction manipulation talocrural joint

Evidence-based Practice

“the integration of best research evidence with clinical expertise and patient values”

D.L. Sackett et al, 2000

Evidence-based Practice

• Admit - do not know it all

• Need to identify knowledge gaps

• Process is systematic and critical

• Prevents belief in evidence that supports preconceived ideas of therapies that are effective

Systematic Reviews

Meta-analyses

Randomized Control Trials

Case Control Studies

Cohort Studies

Ideas, Editorials, Opinions

Animal research

“Best” Evidence

Clinical Expertise

The ability to use our clinical skills to rapidly identify each patient’s unique health state.

Patient Values

This includes a patient’s unique preferences, concerns, and expectations as part of the clinical decision-making and management processes.

Treatment Today

• Outcome measure

• Improve diagnosis

• Measure ROM

• More education – ergonomics

• Patient more involved

Canadian Approach

• Recognized worldwide

• Eclectic approach

• Lamb, Morgan, Fowler, McGregor, Oldham, Lee and many others

What must improve

• Better classification of syndromes

• Cluster of tests and treatment approaches

• Improve reporting results of Systematic Reviews

                                                                     

What will change

• Gold standards improve- MRI’s

• FCAMT’s increase in publishing

• More recognition for MT research

• Evaluate mechanisms – apply to techniques

                                             

“A new orthopaedic stream within the M.Sc. program began in September 2002. This program provides training in advanced manual therapy and research methods concurrently”

MSc – Orthopaedic Stream

Evidence – based Practice

Imperfect but necessary

Two LBP Cases

• Discuss the 2 cases

Use these headings

• Contributing Factors

• Clinical Hypothesis

• Treatment Approach

• Prognosis