Joint Motion: Terminology and Biomechanics

Terminology

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

Biomechanics of Joint Motion

• Physiological motion is done voluntarily by the patient
• Physiological motion results from concentric or eccentric muscle contractions
• Bones move about an axis via flexion, extension, abduction, adduction, or rotation during physiological motion
• Accessory motion cannot be voluntarily performed
• Accessory motion involves the motion of articular surfaces relative to one another
• A full range of physiological motion requires accessory motion
• Ligaments and the joint capsule influence accessory motion

Indications for Manual Therapy (MT)

• Mechanical Joint Pain
• Joint Hypomobility (Joint Mobility Impairment)
• ROM impairments
• Following Immobilizations
• Post-Injury
• Adhesive Capsulitis
• Impingement Syndrome
• Carpal Tunnel Syndrome (CTS)
• Lateral Epicondylalgia
• Hip & Knee Osteoarthritis (OA)

Osteopathic Model

• Andrew Taylor Still developed the model in 1874
• Still trained as an MD but rejected traditional medicine
• Still established the American Osteopathic College in Kirksville, MO in 1896
• The Law of Artery states that manipulation of the spine restores blood flow which allows the body to heal
• Doctors of Osteopathic Medicine (DOs) have the same practice rights as Medical Doctors (MDs) in all 50 states

Chiropractic Model

• Daniel David Palmer established the model in 1895
• Palmer adjusted a patient at the T4 level which restored lost hearing
• The term "Cheiros" means hands and "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
• Chiropractors treat subluxations with spinal adjustments
• The Law of the Nerve states that adjusting spinal subluxations restores nerve flow and facilitates body's healing ability

McMillan's Text

• McMillan describes massage as movements done upon the body
• McMillan used the word "manipulation" throughout her book to describe techniques such as effleurage, tapotement, friction massage, and paddle technique

Legislative Challenges for Physical Therapists (PTs)

• Opposition to PTs performing manipulation began in the 1900s
• Opposition intensified in the 1990s due to PT movement towards direct access and doctoral education.
• By 1998, 23 states had legislative challenges
• Legislative and regulatory challenges are decreasing in number, but increasing in intensity
• The chiropractic profession is the primary challenger.
• Professional training of PTs is the target
• The educational standards for PTs weren't clear until the 2004 version of the Normative model and CAPTE criteria

Physical Therapy Profession Response

• The Orthopaedic section of the APTA was founded in 1974 to mobilize an organized response to chiropractic challenges
• The American Academy of Orthopedic Manual Physical Therapists (AAOMPT) was founded in 1992 partially to meet international standards of residency and fellowship training in Orthopedic Manual Physical Therapy (OMPT)
• The APTA Manipulation Task Force was formed in 1999 to coordinate APTA/AAOMPT response to chiropractic legislative challenges

State Practice Acts

• Many state practice acts are silent on manual therapy and manipulation
• Four states restrict a PT's ability to perform manipulation
• These states are Arkansas, Washington (endorsement), West Virginia, and Indiana
• Therapists must be aware of practice laws in their states

Physical Therapy Education/Curriculum

• CAPTE evaluative criteria requires 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 further enhance the instructional level in manipulation
• Textbooks such as "Manual Physical Therapy of the Spine" are written by PTs
• PT education focuses on emphasis on problem-solving and the use of an evidence-based approach
• PT education focuses on clinical decision-making and meeting educational objectives
• Thrust techniques are integrated into clinical science courses rather than 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
• PT education provides a foundation for determining the clinical decision-making needed for thrust techniques
• Students receive psychomotor training and testing required for safe applications of thrust and non-thrust techniques

APTA Position

• PTs are the leaders in the diagnosis and management of "Movement" Disorders
  • Evidence supports the judicious use of manipulation in PT practice
• Professional Associations promote and protect the scope of this type of PT practice

Safety

• The Risk of cauda equina syndrome is estimated to be 1 in 100 million manipulations
• The risk associated with NSAID usage is gastrointestinal bleed which occurs in 1-3/100 patients
• Serious complications of cervical manipulation ranges from 1 per 400,000 to 3-6 per 10 million
• There are no reports of complications related to extremity manipulation
• The most common adverse effects include headaches, stiffness, and local discomfort

Studies on Cervical Manipulation

• Studies of cervical manipulation on the vertebral artery and cerebral hemodynamics included 20 patients with neck pain, mean age 32
• There was a decrease in contralateral blood flow velocity with neck rotation and with manipulation
• Brain blood perfusion changes weren't seen with neck rotation
• Any changes observed are likely not clinically meaningful, suggesting manipulation may not increase cerebrovascular event risk through a hemodynamic mechanism

Risk-Benefit Assessment of Spinal Manipulation

• The incidence of Cervical Artery Dissection (CAD) in the general population is 2.9/100,000
• Reported cases have been unable to demonstrate causality with cervical mobilization/manipulation
• There are questions about whether the CAD symptoms are what led the patient to seek manual therapy, or if the manual therapy actually provoked CAD in someone without a prior complaint
• The most common symptom of CAD is headache or neck pain
• The World Health Organization (WHO) regards manual mobilization and Spinal Manipulation Therapy (SMT) to be safe and effective

Quantifying Risk

• It's impossible to determine the precise risk
• There are events that aren't published in peer-reviewed literature
• There's no accepted standard for reporting these injuries
• The Risk of serious complications is low
• An estimated 1 in 10 cases of serious adverse events with spinal manipulation are reported in literature

Risk Assessment for Stroke

• Factors to assess when considering stroke risk include:
• History of cervical spine trauma
• History of migraine headaches
• Hypertension
• Cardiovascular disease and blood clotting disorders
• Diabetes
• History of smoking
• Recent infection

Red Flags

• Significant trauma
• Weight Loss
• Steroid use
• Patient is over 50 years old
• History of Cancer
• Severe, unremitting night-time pain
• Fever
• Pain that gets worse when lying down
• Intravenous drug use

Accessory Motion Grading

• 0 = No movement and indicates hypomobility
• 1 = Considerable decreased movement and indicates hypomobility
• 2 = Slight decreased movement and indicates hypomobility
• 3 = Normal movement
• 4 = Slight increased movement and indicates hypermobility
• 5 = Considerable increased movement and indicates hypermobility
• 6 = Complete instability and indicates hypermobility

Physiological Effects of Mobilization/Manipulation

• Stretching of periarticular tissue
• Disrupting intra-articular adhesions
• Restoring normal articular relationships
• Enhancing fluid exchange
• Hypoalgesia -increases pain threshold
• Normalizin" neurophysiologic reflexes

Effects of Mobilization/Manipulation

• In vivo measurements of P-A, short lever thrust manipulation shows it is multiaxial and coupled vertebral displacements that increase in association with the amount of force and contact point
• "Cavitation" occurs in multiple joints with manipulation
  • Most of the time 2-6 cavitations occur per thrust
  • Cavitations typically take place within one segmental level of the target
    • Which equals "general accuracy
• Neurophysiological effects stimulate muscle spindle afferents and Golgi Tendon Organs (GTOs); this alters muscle contraction
• Alters pain processing by increasing pain tolerance or its threshold
• Stimulates paraspinal muscle reflexes and alters motor neuron excitability
• The CNS "adds a novel sensory input or remove[s] a source of aberrant input"

Clinical Prediction Rule (CPR) for Manipulation

• Recent onset is the presence of symptoms in less than 16 days
• A low FABQ score is less than 19
• No symptoms are distal to the knee
• Lumbar stiffness or hypomobility
• Good hip Internal Rotation greater than 35°
• The presence of 4/5 variables leads to a Positive Likelihood Ration (+LR) of 24.38

Clinical Prediction Rule (CPR) for Patients with Neck Pain

• Symptoms present for less than 30 days
• No symptoms distal to the shoulder
• Extension does not aggravate symptoms
• The Fear Avoidance Beliefs Questionnaire (FABQ) score is less than 12
• Decreased upper thoracic spine kyphosis
• Cervical extension Range of Motion (ROM) is less than 30°
• The presence of 3/6 variables leads to a Positive Likelihood Ratio (+LR) of 5.5 and improves the probability of success from 54% to 86%

Joint "End Feel"

• A normal capsular end feel presents with a firm resistance
• A normal bone-to-bone end feel presents with a hard resistance
• A normal tissue approximation end feel feels soft
• An abnormal capsular end feel will differ per structure involved
• An abnormal bone-to-bone end feel will differ per structure involved
• Spasms are an abnormal end feel
• A springy block is an abnormal end feel
• An empty end feel is abnormal

James Cyriax

• Correct diagnosis is essential to ensure effective treatment
• James Cyriax focuses on selective tissue tension examination
• There are 3 basic principles:
  • All pain arises from a lesion (a 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- also known as prolotherapy

Freddy Kaltenborn

• Was the first to relate mobilization and manipulation to arthrokinematics
• Mobilization's purpose is to restore normal glide between joint surfaces
• Mobilizes according to the convex/concave rule- in open chain
• Convex on concave is opposite
• Concave on convex is same

Treatment Direction

• The Treatment plane lies on the concave articulating surface and is perpendicular to a line from the center of the convex articulating surface
• Joint traction techniques are applied perpendicular to the tx plane
• The entire bone is moved so that the joint surfaces are separated
• Joint glides are applied parallel to the Treatment plane

Traction

• Traction is applied in 3 stages:
• Stage 1: neutralizes pressure in joint without separating surfaces
• Stage 1 is used for pain control
• Stage 2: separates joint surfaces
• Stage 3: creates distraction and stretches soft tissue

John Mennell

• Joint dysfunction is a loss of one or more movements of an involuntary nature which occur at any synovial joint
• Involuntary movement equals joint play
• Causes of joint dysfunction include disuse, aging, immobilization, and intrinsic trauma
• John Mennell addresses diagnosis from a standard, systems review approach

Mennell's Basic Truisms

• If a joint cannot move, the muscle that moves that joint also cannot properly move the joint
• Normal muscle function depends on normal joint movement
• Impaired muscle function perpetuates and may cause deterioration in abnormal joints

Mennell's Treatment

• Manipulation treats joint dysfunction, passively moving joint beyond the physiological limit of range but within the anatomical limit of joint motion
• Mobilization is followed by muscle reeducation procedures
• Spray and Stretch techniques are used to treat muscle dysfunction

Geoffrey Maitland

• Careful examination is the foundation of tx
• Pain, stiffness, and spasms during active and passive physiologic and accessory movements determine treatment
• Functional Limitations are noted and reassessed

Maitland Exam

• Through subjective history, the patient is questioned extensively, and the importance of verbal communication is emphasized
  • It focuses on positive empathetic commitment to understanding the pain experience
  • The relationship between the sx and functional activities must be understood
• Through physical exam, the therapist will establish if combination of findings are comparable to what they learn during the history
• The reproduction of symptoms vs the production of symptoms

Maitland Treatment

• Mobilization is performed with oscillatory mvmts, which are divided into four grades:
• Grade I: small amplitude at the beginning of range
• Grade II: large amplitude within range
• Grade III: large amplitude at end range
• Grade IV: small amplitude at end range

Considerations for Mobilization

• Grade I and II Mobilizations address neurophysiological effects of pain control and neutralize joint pressures
• Grade III and IV Mobilizations increase Range of Motion (ROM) through stretching of shortened tissues and are performed at the end range of tissue resistance

General Considerations for Orthopedic Manual Therapy

• A therapist uses good body mechanics during treatment
• The Patient's position should be comfortable
• Respect the patient's personal space
• Utilize long lever vs short lever techniques
• Alter the hand contact point of the therapists' hands based on patient size
• Modify manual interventions to accommodate individual therapists and patients

Applications

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

Technique Variables

• The Physical Therapist makes the decision on the following questions during their assessment
• What is the Patient's appropriate treatment position to put them in?
• What is the best Joint position for treatment to be most effective?
• How much forces is the therapist applying?
• What direction is that force going?
• Is there a Combination of accessory and physiologic movements?
• Should the therapist be utilizing Oscillations or Sustained holds?
• Should the therapist be utilizing Oscillations frequency
• What should the Tx duration for an intervention be?
• Shoudl the therapists be Adding traction and the associated levels Prior to mobilization force?

Post-Mobilization Consideration

• Determine the Severity of patient condition which in turn classifies it as mechanical vs non-mechanical pain
• Determining the Level of patient Joint irritability indicates if the patient presents dependence on Physical THerapy for pain relief
• Assess the patient's prior experience with mobilization for the direction they were delivered
• Assess Fear avoidance beliefs.
• Also asses all contraindications or precautions before delivering a new intervention

Contraindications

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

Standardized Terminology

• Rate of force application
• Location in range of available movement
• Direction of force
• Target of force
• Physical Therapist position

Visceral and Systemic Causes for Headache

• 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

• The patient describes that they hae a "Thunderclap headache", or that it is very intense and acute.
• New Headache when age >50 years old or 10 year old
• Persistent morning Headache without nausea.
• New onset Pain in patient when they have a current or past medical history of CA or HIV.
• Progressive HA, worsening over weeks.
• Headache w/ postural changes.
• Visual symtpoms greater than 1 he when include motor weakness, different than any prior auras, or that it occurs the first time after starting oral contraceptives

Important General Rules

• Each distinct headache type must be separately diagnosed and coded–thus that a patient may has different types of Pain
• List multiple diganosis in an order of importance
• If a single diagnosis is to be delivered, all listed criteria to achieve that diagnosis criteria must be satisfied.

Diagnostic Headache Diary

• If a patients has mulitple types of symptoms, track them with an intensive diary
• These diaries will help improve diagnostic accuracy
• It helps the process of judgment for medication consumption from patient perspective and compliance
• It makes patient's conscious of the amount pain they experiance that are unique sub diagnoses
• It educates patients how to distinguish between unique and complex conditions

Types Major Primary HeadAches

• Migraine: Includes with or withour an associated aura
• Tension headaches: very common
• Trigeminal Autonomic Cephalalgias: Includes "Cluster Headaches
• All other: Any other primary Pain

Migraine without Aura

• Pain lasting for a duration Pain ranges from 4-72 hours, with or without treatment

• The patient has atleast"2"of the Symptoms:

• Pail that presents with unilateral body location

• That produces throbbing pain

• That produces moderate or severe pain

• That increases pain due with typical aggravation of pain

• =1 other symptoms:

• Pain related symptom of Nausea with or without vomiting

• Photosensitivity

• Phonophobia

• Cannot be explained by a medical diagnosis

Migraine with Aura

• Describes recurring Pain for small increment of time, which is unilateral body sensation
• It presents with visual pain, or other pain in brain,
• Greater than or equal to 1 fully réversible symtpoms:
• visual,
• sensations,
• speech,
• motor,
• brainstem,
• retinal

TTH: Diagnostic Criteria for infrequent episodic pain

• Occurs less than once a month and for less than a year combined of time within the parameters
• Pain length 30 min up to 7 days

=2, all of the characteristics: that presents and is bilateral in area,

• Pain produces pressure, pain produces tightening pain is neither aggressive when working

• No nausea with potential for some anorexia symptoms

• Photophobia with phonophobia - no more than one is a symptom

TTH: diagnostic criteria for frequent episodic

• 1 up through 14 times a monthly
• <"3 month as a marker "> "12 and 180 yearly range"
• Pain length 30 min up to 7 days

=2, all of the characteristics:

• Pain presents and is bilateral in area

• Produces pressure and that results from tightening

• Pain is neither in its aggrivation as results from the work that someone performs.

• No nausea, or a small list of symptoms such as potential anorexies

• Photophobia with phonophobia are one of two, and can't both exist.

TTH: diagnostic criteria, for persistent pain

=15 events monthly for >3 for some length

• Pain length will range from long hours of time up to days

• At least 2, for the following listed conditions:

• • Pressure and location on area. will produce mild irritation on area. produces pain that is unaffected from work life.

• A combination must happen of all the options: Photophobia/ Phonophobia if a combination of less will.

• No effect, or light if light symptom effects occur.

Cluster headache

• At least 5 cluster attacks.

• Severe or very severe orbital or "in top of" eye, for a time span of a range can last 15 min and that can be determined from outside source..

• At Least one of the requirements happen

• At least have more than one related condition. One side of the conjunctiva is a reddened symptom and will produce eye tears. , swelling on one side of the eye.. The other symptom is to feel irritated with a general lack of focus, that is present a patient feels

Secondary HA

• Pain associated with the problem, which must be known of.
• Pain that happens as and with it, and that relates to how the underlying condition. Reduced Pain once successful in treatment

Cervi HA

• A standard exam with a medical to determine that an existing anatomical deformity is creating the pain.
• A typical exam will reveal that
• flexion and rotational testing, with cervical spine rom is limited.

Cervy Diagnostic Criteria

• A medial test can produce to display a known HA deformity Pain must show that it progresses.

• HA improvements will be noticeable upon improving cervical spine limitations. Limitations that will appear with symptoms, such as proactive testing to reproduce Pain HA is improved once a blockade occurs towards the deformity, as one can see from the patients system.

Cervics and brain connections

Remember if afferents in areas join over in secondary neurons that run in SC for example then symptom Pain can be created and be directed as areas "that can be" where " other can arrive" from brain location.

• The greater brain regions in fore head are associated as that connect with neck region. The lower brain connects to the region near neck.

PT mngment, cerv ha

• patient education

• Manipulation of tissue in area

• Neck or nearby location movement. or manipulation

• Methods

• Rest and sitting straight

• Analysis

• Controlling factors, outside the body

• Manipulation on spine towards chronic pain

Systematic Review

• Combination of three pain Manipulation is great as can be seen on how it deals more like on is, is shown to "help equal out effects as medications"
• May give relief over migraine symptoms
• However this is lacking

Biopsychosocial method

• Has a long data for doing this when creating treatment limit is for pain related treatment Focus from pathology of system to improve the individual being treated.

Method with Brain influence

• Support over system
• Ideas, that is behavior can assist pain system to improve

Brain Cognitive Idea

• Help system
• Give patient mind related tactics that help manage symptoms. Help patient thoughts that are helpful. Combine movement and focus that promotes mind and motor integration.

Brain influence related factors

• All of an "mind side" to problem can effect
• Thoughts
• Ideas that shape ones life
• Behaviors shaped from ones choices

Action

• To solve bad actions
• Try to solve the problem you have
• If a symptom feels out of place then get assistance

Pain and mind relations in bad ways

• Stress increases pain
• Thoughts decrease the action, to remove the cause.

The Mind Side Effect

• Support symptoms
• Educated mind techniques

Action

• Teach over and over actions that can work
• Create positive energy in actions
• Rest the body to calm it

Explain

• Talk about " Hurt compared to Hurt"

• Provide tactic of control

• Be careful over words use over symptom

• Teach what is related to pain

• Move " bad energy from site"- To think about brain

• Be useful improving actions that a person can make

What does it mean

• The person's experience of what pain looks like in unique
• • Give story
• Not use models from body Focus over what the nerves do in region

Skill train

• Learn the actions or what they provide over each set of actions

Body position

• Provide energy
• Use what happens to calm

Clear the energy the brain can provide to work

• Be confident
• Provide focus during the time
• It does not stop until finished
• The body with focus over how pain changes over long term Provide to talk with patient to separate action.

What to teach for action plan

• Help the rational behind reason to to this
• Energy increases the pain "If those move will have less pain"

Rest the mind

• Pain increases the stress on "arthritis"

• " if those rest they feel better" break it down over the time needed on them.

Brain help

• What the patient does helps calm them.
• Think over those the can happen.
• Focus out and around over what is.

Brain training

• Bad idea comes to mind

• Then we will use one good

• Give good points that that can support a better outcome and the patient can use control

Position action

• Over activity tolerance, increase position with those listed
• time standing versus movement or repetition

Sleep problems

• Are very much present on ones body

• is a cause for concern, that affect health and actions one provide.

• is a requirement, that can effect ones system

• Health - what fixes and improves it all.

• What the mind does is effected

• Focus is limited

• Body gets worse quicker after it is already declining body

It is a important to think

• It may give

• increase pain, worse health

• lose function decrease what ones body all the time provides.

• Mind will worsen slowly

• memory is effected

• Body "can fall"

Problems

• Difficult to sleep

• Stop during.

• Or go up on system without a clear cause that can effect

• Bad area blockage: that is from bad area sleep

• Nerve problem cause urge to move while "stopping" a function. The feeling of the place moving may work but to that end it is not something.

Support

• The power of the body increases without stress
• Energy and depression will work.