Joint Motion Biomechanics

Terminology

• Thrust manipulation involves high velocity, low amplitude therapeutic movements at or near the end-range of motion.
• Non-thrust manipulation includes mobilizations that don't involve thrust.
• Arthrokinematics refers to the motions of bone surfaces within a joint, including roll, spin, slide, compression, and distraction.
• Osteokinematics involves angular joint movements, specifically cardinal plane movements of bony levers.

Biomechanics of Joint Motion

Physiological Motion

• Movements are performed voluntarily by the patient.
• Concentric or eccentric active muscle contractions contribute to physiological motion.
• Bones move about an axis through flexion, extension, abduction, adduction, or rotation.

Accessory Motion

• These motions cannot be performed voluntarily.
• They describe the movements of articular surfaces relative to one another.
• Accessory motion is necessary for full range of physiological motion.
• Ligaments and joint capsules influence motion.

Indications for Manual Therapy

• Mechanical joint pain can be treated with MT
• Joint hypomobility, or restricted joint mobility, can be treated with MT
• ROM impairments can be treated with MT
• Post-immobilization stiffness can be treated with MT
• MT can be used post injury
• Condition-specific uses include adhesive capsulitis, impingement syndrome, carpal tunnel syndrome (CTS), lateral epicondylalgia, and hip/knee osteoarthritis (OA).

Osteopathic Model

• Developed in 1874 by Andrew Taylor Still
• Still, although trained as an MD, rejected medicine.
• The American Osteopathic College was established in Kirksville, MO, in 1896.
• The Law of Artery states that spinal manipulation restores blood flow and the body's healing ability.
• Currently, Doctors of Osteopathic Medicine (DOs) have the same practice rights as medical doctors (MDs) in all 50 states.

Chiropractic Model

• The model was established in 1895 by Daniel David Palmer.
• Palmer adjusted a patient at the T4 level, which led to restoration of lost hearing.
• Cheiros means hands + praktos means done by.
• Palmer College opened in 1897 in Davenport, Iowa.
• Doctors of Chiropractic (DCs) are the largest group of primary care physicians outside of medicine.
• Spinal subluxations are treated with spinal adjustments.
• Law of the Nerve: spinal subluxations are adjusted to restore nerve flow and facilitate the body's healing ability.

McMillan's Text

• Massage (manipulation) involves movements performed on the body.
• The word "manipulation" describes techniques like effleurage, tapotement, friction massage, and paddle technique.

Legislative Challenges and PT Response

• Opposition to PTs performing manipulation began in the 1960s.
• Opposition intensified in the 1990s due to PT movement toward direct access and doctoral education.
• 23 states had legislative challenges by 1998.
• The number of legislative challenges is less per year, but the intensity of challenges continues.
• The chiropractic profession is the primary challenger.
• Professional training is a focus of legislative challenges.
• Clear educational standards were absent until the 2004 version of the Normative Model and CAPTE criteria.
• The Orthopaedic Section of APTA was founded in 1974 to mobilize an organized response to chiropractic challenges.
• AAOMPT was founded in 1992 partly for the same purpose: to meet international standards for residency/fellowship training in Orthopedic Manual Physical Therapy.
• The APTA Manipulation Task Force was formed in 1999 to coordinate APTA/AAOMPT response to legislative challenges.
• Many state practice acts are silent on manual therapy and manipulation.
• Four states restrict PTs' ability to perform manipulation, including Arkansas, Washington (endorsement), West Virginia, and Indiana.
• Therapists must be aware of practice laws in their states.

PT Education/Curriculum

• CAPTE evaluative criteria require PT education programs to teach thrust and non-thrust manipulation of the spine and extremities.
• The Manipulation Education Manual (APTA/AAOMPT) was developed in 2004 to enhance the level of instruction in manipulation.
• Textbooks cover "Manual Physical Therapy of the Spine."
• PT education emphasizes problem-solving and evidence-based approaches.
• Clinical decision-making and meeting educational objectives are the focus of PT education.
• Thrust techniques are integrated into clinical science courses, not stand-alone courses.
• Advanced specialty PT training is obtained through long-term fellowship programs.
• PT education emphasizes movement sciences and analysis.
• Expertise is grounded in anatomy, physiology, biomechanics, and pathology.
• This provides a foundation for determining clinical decision-making needed for thrust techniques.
• The psychomotor training and testing is required for safe applications of thrust and non-thrust techniques.

APTA Position

• The APTA supports evidence-based practice.
• PTs are leaders in diagnosing and managing movement disorders.
• Evidence supports the judicious use of manipulation in PT practice.
• Professional Associations promote and protect the scope of practice.

Safety Considerations

• Cauda equina syndrome risk is estimated at 1 in 100 million manipulations.
• Risks are associated with NSAIDs (GI Bleed), with a rate of 1-3/100.
• Serious complications from cervical manipulation range from 1 per 400,000 to 3-6 per 10 million.
• No reports of complications related to extremity manipulation.
• Common adverse effects include headache, stiffness, and local discomfort.

Studies: Cervical Manipulation

• A study on cervical manipulation and cerebral hemodynamics included 20 patients with neck pain (mean age 32).
• A decrease in contralateral blood flow velocity occurred during neck rotation and manipulation.
• Brain blood perfusion changes were not seen with neck rotation.
• Changes observed were likely not clinically meaningful, suggesting manipulation may not increase cerebrovascular event risk through hemodynamics.
• The risk-benefit ratio considers excluding cervical artery dissection in spinal manipulation therapy.

Risk-Benefit of Spinal Manipulation

• Incidence of CAD in the general population is 2.9/100,000.
• Cases reported have been unable to demonstrate causality with cervical mobilization/manipulation.
• HA or neck pain is the most common symptom of CAD.
• HA may lead the patient to seek manual therapy, or manual therapy may provoke CAD with a non-CAD complaint.
• WHO deems manual mobilization and SMT safe and effective.

Quantifying Risk

• Determining precise risk is impossible due to underreporting and lack of accepted reporting standards.
• The risk of serious complications is low.
• Only 1 in 10 cases of serious adverse events are reported in the literature.

Risk Assessment: Stroke

• Examine the History of C spine trauma
• Examine the History of Migraine HA
• Examine the History of Hypertension
• Examine the History of CV Disease/Blood Clotting Disorders
• Examine the History of Diabetes
• Examine the History of Smoking
• Examine the History of Recent Infection

Red Flags

• Significant trauma
• Weight loss
• History of cancer
• Fever
• Intravenous drug use
• Steroid use
• Patient is over 50 years old
• Severe, unremitting nighttime pain
• Pain that worsens when lying down

Accessory Motion Grading

Joint Mobilizations

• 0: No movement
• 1: Considerable decreased movement
• 2: Slight decreased movement
• 3: Normal
• 4: Slight increased movement
• 5: Considerable increased movement
• 6: Complete instability

Joint Assessment

• Hypomobility is decreased movement
• Normal is the normal amount of movement
• Hypermobility is increased movement

Physiological Effects of Mobilization/Manipulation

• Stretching of periarticular tissue occurs.
• Intra-articular adhesions are disrupted.
• Normal articular relationships are restored.
• Fluid exchange is enhanced.
• Hypoalgesia occurs (increased pain threshold).
• Neurophysiologic reflexes are normalized.

Effects of Mobilization/Manipulation

Mechanical

• In vivo measurements of P-A, short lever thrust manipulation show multiaxial, coupled vertebral displacements increasing with force, varying by contact point.
• Cavitation occurs in multiple joints with manipulation, typically 2-6 cavitations per thrust.
• Cavitation mostly occurs within one segmental level, achieving general accuracy.

Neurophysiological-Inflow Sensory Info Into CNS

• Stimulation of muscle spindle afferents and GTOs alters muscle contraction.
• Pain processing is altered, increasing pain tolerance or its threshold.
• Paraspinal muscle reflexes are stimulated, altering motor neuron excitability.
• This may add novel sensory input or remove a source of aberrant input.

CPR for Manipulation

• Recent onset (less than 16 days)
• Low FABQ score (less than 19)
• No symptoms distal to the knee
• Lumbar stiffness/hypomobility
• Good hip IR (greater than 35°)
• Presence of 4/5 = +LR 24.38

CPR for Patients with Neck Pain

• Symptoms less than 30 days
• No symptoms distal to the shoulder
• Extension does not aggravate symptoms
• FABQ score less than 12
• Decreased upper thoracic spine kyphosis
• Cervical extension ROM less than 30°
• 3/6 variables (+LR 5.5), the probability of success improved from 54% to 86%.

Joint "End Feel"

Normal

• Capsular: Firm
• Bone-to-Bone: Hard
• Tissue Approximation: Soft

Abnormal Pathologic

• Capsular*
• Bone-to-Bone*
• Spasms
• Springy Block
• Empty

James Cyriax

• Correct diagnosis is essential to ensure treatment is effective.
• Selective tension examination should take place.
• There are three basic principles:
  • All pain arises from a lesion (pathological or traumatic discontinuity of joint or soft tissues).
  • All treatment must reach the lesion.
  • All treatment must exert a beneficial effect on the lesion.

Cyriax Interventions

• Steroid injections for acute conditions
• Deep friction massage for soft tissue adhesions
• Mobilization/manipulation to break adhesions and mobilize loose cartilage
• Sclerosing injections to treat unstable joints (prolotherapy)

Freddy Kaltenborn

• Related mobilization and manipulation to arthrokinematics
• The purpose of mobilization is to restore normal glide between joint surfaces.
• Mobilization follows the convex/concave rule in open chain
  • Cave on Vex: Same
  • Vex on Cave: Opposite

Treatment Direction

• The treatment plane lies on the concave articulating surface, perpendicular to a line from the center of the convex articulating surface.
• Joint traction techniques are applied perpendicular to the treatment plane, moving the entire bone to separate joint surfaces.
• Joint glides are applied parallel to the treatment plane.
• Traction is applied in three stages:
  • Stage 1: Neutralizes pressure in the joint without separating surfaces (used for pain control).
  • Stage 2: Separates joint surfaces.
  • Stage 3: Creates distraction and stretches soft tissue.
• Accessory movements are applied with sustained tractions.
• Stretch localized to tight portions of the capsule or surrounding soft tissue emphasizes mechanical effects and treats to the anatomical limit of the joint.

John Mennell

• Joint dysfunction is the loss of one or more involuntary movements occurring at any synovial joint.
• Involuntary movement is synonymous with joint play.
• Causes of joint dysfunction include disuse, aging, immobilization, and intrinsic trauma.
• Diagnosis comes from a standard, systems-review approach.

Mennell's Basic Truisms

• When a joint cant move the muscle that moves it can be free to move
• Muscles cannot be restored to normal if the joints which they move are not free to move
• Normal muscle function is dependent upon normal joint movement
• Impaired muscle function perpetuates and may cause deterioration in abnormal joints

Mennell Treatment

• Manipulation is used to treat joint dysfunction
• Passively move the joint beyond the physiological limit within the anatomical limit .
• This is followed by muscle reeducation procedures
• Spray and stretch” technique treat muscle dysfunction

Geoffrey Maitland

• A careful examination is foundation of treatment
• Correlation of pain, stiffness and spasms determine treatment
• In coordination with active/passive physiologic/accessory movements determine treatment
• Functional limitations are noted and reassessed.

Maitland's Subjective History, Physical Examination, and Treatment

Subjective Hx

• The patient is questioned extensively.
• Verbal communication is emphasized.
• A positive personal commitment theme is needed
• The relationship between their symptoms and activities must be established.

Physical Examination

• Combination of pain, stiffness, and spasms that the examiner finds on examination correspond with the patient's symptoms.
• Reproduced vs produces pain should be recorded

Treatment

• Mobilization is performed with oscillatory movements.
  • Grade I: small amplitude at the beginning of a range.
  • Grade II: large amplitude within range.
  • Grade III: large amplitude at end range.
  • Grade IV: small amplitude at end range.

Considerations

Grade I and II Mobilizations

• Produce a neurophysiological effect of pain control Neutralizes joint pressures

Grade III and IV Mobilizations

• Increase ROM through stretching of shortened tissues Performed at end range of tissue resistance

General Considerations for Orthopedic Manual Therapy

• Therapist should utilize good body mechanics.
• Patient position should be comfortable.
• Therapists must respect patient “personal space."
• Long lever vs short lever technique
• Hand contact point should be altered based upon relative size of target structures
• Modification may be necessary to accommodate individual issues

Application

• Grade I and IV rapid movements (60-120/min)
• Grade II & III are slow and smooth, regular oscillations (5-60/min)
• 1-5 repetitions and reassess
• Slow speed stimulates mechanoreceptors.
• Slow speeds inhibit muscle guarding
• Faster speeds with low amplitude to inhibit pain
• Open packed position,distraction techniques for painful joints
• Sustained holds at end range can be used for restricted joints 6-30 seconds, repeat several times

Technique Variables

• Patient position
• Joint position
• Amount of force
• Direction of force
• Combination of accessory & physiologic movement
• Oscillations vs sustained hold
• Oscillations frequency
• Treatment duration
• Addition of traction (& level) prior to mobilization force

Post Mobilization

• The severity of condition (Mechanical vs non-mechanical pain)
• Level of irritability of joint (Pt dependence on PT for pain relief)
• Previous experience mobilizing (Pt directed vs therapist directed forces
• Fear avoidance beliefs (contraindications/precautions)

Contraindications

• Malignant lesions in the region of treatment
• Metabolic bone disease
• Joint infection/osteomyelitis
• Bony fusion of the joint
• Fracture
• Compromised joint integrity

Standardized Terminology

• Rate of force application
• Location in the available movement
• Direction of force
• Target force
• Patient position

Visceral and Systemic Causes of HA

• Stroke/TIA
• Hypertension
• Infection (ear,sinus,flu,pneumonia,etc)
• Digestive Disturbances
• Kidney Failure
• Glaucoma
• Head Injury/concussion/subdural hematoma
• Meningitis/Encephalitis
• Brain Tumor/Aneurysm

Red Flag Symptoms in Headache

• "Thunderclap headache" (intense/hyperacute)
• New onset HA age >50; age Improve diagnostic accuracy
• Allows judgment of medication consumption
• Establishes the quantities of each of two or more different HA types or subtypes
• Teaches the patient to distinguish between different HA’s

Primary Headaches

• Migraine (with or without aura)
• Tension-type HA (most common)
• Cluster HA and other Trigeminal Autonomic Cephalalgias (TAC)
• Other primary HA

Migraine Without Aura

• Attacks lasting 4-72 hours (untreated)
• The patient has >2 unilateral location pulsating quality moderate/severe pain intensity aggravation by/ causes avoidance
• During HA the patient has >1 nausea/vomiting photophobia and phonophobia
• Cannot be better accounted for by another ICDH-3
• Migraines occur more often bilaterally in childten and adolescents

Migraine With Aura

• The patient endures recurrent attacks for lasting minutes of unilateral, fully reversible visual, sensory/other CNS symptoms
• Symptoms occur usually developing gradually and followed by HA usually associated migraine symptoms

TTH Diagnostic Criteria

Infrequent Episodic Criteria

• Have at least 10 episodes occur on 3 months (>12 and 3) criteria
• bilateral location and feel pressing/tightening (non-pulsating quality)
• intensity is mild to moderate
• The pain is not aggravated by routine physical activity (walking/stairs)

Common diagnostic Criteria

• no nausea/vomiting occur
• no more than one symptom photophobia or phonophobia

Cluster Headache Diagnostic Criteria

• At least 5 attacks occurred
• Patient reports severe or very severe unilateral orbital pain/ supraorbital
• Temporal pain will last 15-180 min
• HA is accompanied by >1 -ips conjunctival injection
• lacrimation with runny nasal congestion rhinorrhoea and eyelids -forehead and facial sweating -miosis or ptosis
• A sense of restlessness or agitation occurs
• Attacks frequency from 1 every other day to 8/day

Secondary Headache

• Another disorder known to be able will demonstrates to cause HA
• HA occurs in a close temporal relation because a casual relationship caused it via a brain tumor
• Symptoms are greatly reduced when treating tumor
• Symptoms are resolved within 3 months after a spontaneous remission of the cause

Cervicogenic Headache

• Clinical exam reveal pain from spine structures (bony, disc tissue)
• Patients will endure decreased cervical range of motion decrease + cervical flexion
• Clinical imaging shows evidence of a disorder via neck known to be able to cause HA
• Develop improvement shown in evidence of a lesion being developed due a cervical disorder

Anatomy of Cervicogenic HA

• Fundamental is via convergence
• Afferents converge in the body through neuron SC activity
• Aching occurs along with body activity
• Orbit results show trigger minal activity
• Occiput convergence results from cervical afferents in the cervical spine

Pt Management: Tension/Cervicogenic HA

• Educate Patient
• Soft tissue mobilization
• Joint mobilization-cervical or thoracic
• Modalities
• Postural/Relaxation Exercise
• Ergonomic Evaluation
• Stress Management
• Spinal Manipulation for Chronic HA

Systematic Review

• Involves manipulation TTH, MH, to CGH
• Manipulation more effective than a massage
• Just as effective a pharmacologic treatment

Evidence Regarding Manipulation

• SM may be effective to reduce migraine days and lower pain
• Given limitations consider study data from meta-analysis that is a preliminary
• Rigorous RCTS are warranted

Upper Cervical Manipulation

• Studies show mobilization and more exercises were effective to reduce HAs
• Effects were maintained for more than 3 months
• Long term effects had less pain through education
• flexion can flex

Biopsychosocial Model

• The Biopsychosocial Model support growing PT practices
• Can use a limited biomedical use to managed issues
• Patient needs supportive practices
• Focuses will always needs pathology treatment
• This Model recognizes the complex bio mechanical function and the psychological

Cognitive behavioral therapy

• This Therapy enhances controls over diversified practices
• Patient can perform beliefs/attitude
• Behaviors play a role
• Goals is to teach patients cognitive behaviors
• Inform patients of behavior, and place role that affects them Exercise that will allow a common approach

Cognitive Behavioral Variables Impacting Pain

• Cognitions: thinking pattern
• Emotions are i.e, mood
• Decreased patterns of activity and reaction to pain
• Patient beliefs will be high for pain tolerance
• Previous experience
• Will perceive that have control through self efficacy
• Distraction imagery
• Depression can relate back to it
• Maladaptive behaviors lead to lack of activity
• Psychotherapeutic will lead to behavior
• PT Education
• Activity and cycling can help relax patient

Treatment Involves

Pain education

Differences between both will help patient to understand

• The patient will require safe strategies
• The patients condition will indicate that pain can show
• Will need to avoid promoting dangerous terms for patients
• Will assist with view, and need to be protected

Pain Neuroscience

• Teach Patients neurobiology/physiology
• This will re direct pain, from pain physiology
• Effecting ways to improve function and pain
• The patient pain should be unique
• Examples of great curriculum with no anatomical references
• Discussions are focus behavior through the patients neurophysiology of pain

Coping skills and techniques

• Relaxation and exercise
• Activity
• scheduling techniques Distrusting of the patients thoughts through cognitive restructuring Patient needs to understand reasons behind therapy
• Will tension and spasms will be relieved
• Needs to be balance tension with exercise and techniques
• Will work groups will allow exercises through tension release

Cognitive and mental distractions

• The patient can visualize relaxing sensations
• Can count numbers/items/objects
• They can slowly back trace by looking at the environment

Thoughts and Exercise’s Cognitive

• First, the patience recognize negative attitudes during times of increased pain
• If patient can recognize adaptive exercise thoughts. Then will reduce pain
• The Affirmation can support through life’s control of pain Exercise will improve activity levels
• Parameters duration frequency with patients
• Limit exercise to progress through pain
• The patients must abate and not make exercise a goal

Sleep and exercise is healthy

• Interference with ⅓ of population issues
• CDC considers to ensure sleep as public
• PT studies display function through sleep balance
• Balance to indicate sleep balance

Functions of sleep

• To ensure function-tissue function and repair modulation cardiovascular health
• cognitive through learning by memory
• PT sleep practice leads to...
• Increases through pain perceptions
• Attentive through the patient functions
• Reduces patient fatigue

Common Sleep Disorders

• Problems will arise
• Inconsistent Sleep that goes up 3 times per month
• Sleep apnea will decrease O2 if blockage occurs and the patient has effort issues

Restless Leg Distress

• The patient has issues while resting they feel that they urge to move
• It feel accompanied by itching or burning
• Movement only assist through relief
• Exercise balance for patients
• Decrease slow sleep wave
• Encourage functions
• Sleep onset to balance
• Weight loss to improve sleep

Back and Leg Pain Surgeries- Criteria

• The patient will be recommended surgery due to fail therapy
• Diagnostical imaging shows problems with symptoms
• The Radicular will start in patterns and cause pain

Conditions of back surgery

• Goals is to balance to a new area
• Decompress a nerve, root, or cord
• Deformities and correct issues

Risks of Spinal Procedures

• Dural Tears
• Nerve Damage
• Bowel And Bladder Incontinence
• Side Effects: Bleeding, Infection, and reactions
• The Patient Has “Failed Back Surgery " after procedure
• Side Effects from the discectomy and laminectomy show
• Spinal fusion symptoms lead
• Kyphoplasty/Vertebroplasty

Diagnosises

Lumbar Disc -

• Radicular shows back and leg more than axial through the back for patient’s that deal with it'
• Improvement show through 6-12 per weeks
• Involvens with L4-L5 AND L5-S1
• Minimally and balance invasively

Procedure Treatment

1. Lift the spine off remove from lig flavum
2. Remove through material of disc

• Muscles remain impact with spinal
• Causes facet to remove spinal balance leads issues
• Advocate early to avoid adhesions

Laminectomy Post Op

• Return ALD 3-4
• For up to a month avoid sitting bending pulling avoid laundry
• Larger procedure that strips all elements with incision
• Is to reduce spinal elements

Process

• All procedure dissected levels and roots due instability
• Facet can removed but stability can effect
• Remove stability due defects
• Variables: The Patient has fatigue with recent level

Balance with immediate functions.

• Protection for bending
• The Basic requires patient mobility
• Walk with mile in control
• Follows the specific of patient condition
• Education- body can sustain ADL
• Walk and follow balanced protocol
• Spinal Procedure- fuse in the region area so it and allow growth and healing

Lumbar Interbo- Fusion

• Insertion of bone with grafts
• Typically is severe and balanced loss of space
• Can treat and prevent loading of fatigue
• Use devices through balance biomechanics

Lumbar Balance Surgery

Balance/ Control

• The effect balance through exercise of level
• Follows that is
• Cardio needs balance.
• Device- follows stems nails of spine
• Balance the issues to allow fusions with stem of device of scoliosis
• Follows one or great previous through spinal issues
• This treatment can work as an alcoholics treatment.

Goal Of The Patient

• Replicate mechanics/posture
• Device will not need fix
• Proper balance biomechanics issues
• Pt outcomes can effect with procedure
• Follow the surgery the technician
• Rehabilitee therapy Kyphoplasty will occur- due to fatigue

Kyphoplasty Balloon

• X guiding while the Balloon and needle meet verte body
• Cement stabilizer
• Pt will be defined
• Inappropriate balance Most lumbar pt have disabilities because of this

Sources can cause FBBS

• The Patient will show balance in decompressed areas
• Shows selections/pain Follow free from a month the scaring or pain through all therapy sessions
• Patients return after 6 post with the pain same way