Joint Motion Terminology & Biomechanics

Terminology

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

Biomechanics of Joint Motion

• Physiological motion is performed voluntarily by the patient
• Physiological motion results from concentric or eccentric active muscle contractions
• Physiological motion involves bones moving about an axis or through flexion, extension, abduction, adduction, or rotation
• Accessory motion cannot be voluntarily performed
• Accessory motion involves the motion of articular surfaces relative to one another
• Accessory motion is necessary for the full range of physiological motion
• Ligaments and the joint capsule influence motion

Indications for Manual Therapy (MT)

• Mechanical joint pain
• Joint hypomobility or joint mobility impairment
• ROM impairments
• Following immobilizations
• Post-Injury
• Certain conditions like Adhesive Capsulitis, Impingement Syndrome, CTS, Lateral Epicondylalgia, Hip & Knee OA

Osteopathic Model

• Andrew Taylor Still developed the Osteopathic Model in 1874
• Still was trained as an MD but rejected medicine
• The American Osteopathic College was established in Kirksville, MO, in 1896
• The Law of Artery states the manipulation of the spine restores blood flow and the body's healing ability
• Doctors of Osteopathic Medicine (DOs) today have the same practice rights as Medical Doctors (MDs) in all 50 states

Chiropractic Model

• Daniel David Palmer established the Chiropractic Model in 1895
• Palmer adjusted a patient at the level of T4, restoring lost hearing
• 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
• Spinal adjustments are used to treat subluxations
• The Law of the Nerve states that adjusting spinal subluxations restores nerve flow and facilitates the body's healing ability

McMillan’s Text

• Massage or manipulation are movements done upon the body
• McMillan used the word "manipulation" to describe techniques like effleurage, tapotement, friction massage, and paddle technique

Legislative Challenges and PT Response

• Opposition to PTs performing manipulation began in the 1900s and intensified in the 1990s due to PTs movement toward direct access and doctoral education
• In 1998, 23 states had legislative challenges regarding PTs performing manipulation
• Legislative and regulatory challenges continue, with the chiropractic profession being the primary challenger
• Focus of legislative challenges are on professional training and educational standards
• There weren't clear educational standards 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
• The AAOMPT was founded in 1992, partially to meet international standards of residency and fellowship training in OMPT.
• The APTA Manipulation Task Force was forced in 1999 to further coordinate APTA/AAOMPT response to chiropractic legislative challenges
• Many state practice acts are silent on manual therapy and manipulation
• Four states restrict PT's ability to perform manipulation: Arkansas, Washington (endorsement), West Virginia, and Indiana
• Therapists must be aware of practice laws in their states

PT Education and 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) developed in 2004 to further enhance the level of instruction in manipulation
• "Manual Physical Therapy of the Spine" and similar textbooks are written with an emphasis on problem-solving and evidence-based approaches
• 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, with expertise grounded in anatomy, physiology, biomechanics, and pathology
• Expertise in movement sciences and analysis provides the foundation for determining 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 practice

Safety

• The risk of cauda equina syndrome is estimated to be 1 in 100 million manipulations
• Risks associated with NSAID use include gastrointestinal bleeding at a rate of 1-3 per 100
• Serious complications of cervical manipulation range from 1 per 400,000 to 3-6 per 10 million
• No reports of complications related to extremity manipulation
• Most common adverse effects include HA, stiffness, local discomfort

Cervical Manipulation Studies

• A study of 20 patients with neck pain with a mean age of 32 showed a decrease in contralateral blood flow velocity with neck rotation and with manipulation
• Brain blood perfusion changes were not seen with neck rotation
• Changes observed are likely not clinically meaningful, suggesting manipulation may not increase cerebrovascular event risk through a hemodynamic mechanism
• The incidence of Cervical Artery Dissection (CAD) in the general population is 2.9/100,000
• There is a lack of demonstrated causality between cervical mobilization/manipulation and CAD
• The question of whether CAD symptoms lead the patient to seek manual therapy or whether manual therapy provokes CAD in those without a CAD complaint remains
• WHO regards manual mobilization and SMT to be safe and effective
• Headache (HA) and neck pain are reported as the most common sx of CAD

Quantifying Risk

• There is an impossibility to determine the precise risk
• There is a lack of publishing all events in peer-reviewed literature
• There is no accepted standard for reporting these injuries
• The risk of serious complications is low
• Serious adverse events with Spinal Manipulation (SM) are reported in 1 in 10 cases

Risk Assessment for Stroke

• History of cervical spine trauma
• Diabetes
• History of migraine HA
• History of smoking
• Hypertension
• Recent Infection
• Cardiovascular Disease/Blood Clotting Disorders

Red Flags for Stroke

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

Accessory Motion Grading

• 0 indicates no movement
• 1 indicates considerable decreased movement
• 2 indicates slight decreased movement
• 3 is normal
• 4 indicates slight increased movement
• 5 indicates considerable increased movement
• 6 indicates complete instability
• Joint assessment includes hypomobility, normal mobility, and hypermobility

Physiological Effects of Mobilization/Manipulation

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

Effects of Mobilization/Manipulation: Mechanical

• In vivo (intraosseous) measurements of effects of P-A, short lever thrust manipulation include multiaxial, coupled vertebral displacements
• Multiaxial, coupled vertebral displacements increase in association with the amount of force and vary based on the contact point
• Cavitation occurs in multiple joints with manipulation
• Most of the time, 2-6 cavitations occur per thrust
• Most cavitations occur within one segmental level of target
• The "general accuracy” can be achieved

Effects of Mobilization/Manipulation: Neurophysiological

• Stimulation of muscle spindle afferents and GTOs-altering muscle contraction
• Altered pain processing: increased pain tolerance or its threshold
• Stimulates paraspinal muscle reflexes and alters motor neuron excitability
• May "add a novel sensory input or remove a source of aberrant input"

CPR for Manipulation

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

CPR for Pts w/ Neck Pain

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

Joint End Feel

• Normal end feels include capsular (firm), bone-to-bone (hard), and tissue approximation (soft)
• Abnormal pathologic end feels include capsular, bone-to-bone, spasms, springy block, and empty

James Cyriax

• Correct dx is essential to ensure tx is effective
• Selective tension examination
• All pain arises from a lesion (a pathological or traumatic discontinuity of joint or soft tissues)
• All tx must reach the lesion
• All tx 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

• Kaltenborn first 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
• A concave surface on a convex surface is same
• A convex surface on a concave surface is opposite

Tx Direction

• The Tx 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 tx plane; the entire bone is moved so that the joint surfaces are separated
• Joint glides are applied parallel to the tx plane
• Traction is applied in 3 stages: neutralizing pressure in the joint without separating surfaces (for pain control), separating joint surfaces, and creating distraction and stretching soft tissue
• Accessory movements are applied with sustained tractions
• Stretch is localized to the tight portion of the capsule or surrounding soft tissue; mechanical effects are emphasized; treats to the anatomical limit of the joint

John Mennell

• Joint dysfunction is defined as a loss of one or more movements of an involuntary nature that occurs at any synovial joint
• Involuntary movement is joint play
• Causes of joint dysfunction include disuse, aging, immobilization, and intrinsic trauma
• Diagnosis is addressed from a standard, systems review approach

Mennell’s Basic Truisms

• A muscle that moves a joint cannot be free to move if that joint is not 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 Tx

• Manipulation is used to treat joint dysfunction to passively move the joint beyond the physiological limit of range but within the anatomical limit of joint motion
• Mobilization is followed by muscle reeducation procedures
• The “Spray and Stretch” technique is utilized to treat muscle dysfunction

Geoffrey Maitland

• Careful examination is the foundation of treatment
• Correlation of pain, stiffness, and spasms during active and passive physiologic and accessory movements determines the treatment
• Functional limitations are noted and reassessed

Maitland

• The patient is questioned extensively
• The importance of verbal communication is emphasized
• The central theme is a positive personal commitment to understanding the patient's pain experience
• The relationship between the patient's symptoms and functional activities must be established
• There is a combination of pain, stiffness, and spasms that the examiner finds on examination and considers to be comparable with the patient's symptoms
• Mobilization is performed with oscillatory movements which are divided into four grades: small amplitude at the beginning of range (Grade I), large amplitude within range (Grade II), large amplitude at end range (Grade III), small amplitude at end-range (Grade IV)

Considerations

• Grade I and II Mobilizations have the neurophysiological effect of pain control, and neutralizes joint pressures
• Grade III and IV Mobilizations increases ROM through stretching of shortened tissues and is performed at end-range of tissue resistance

General Considerations w/ Orthopedic Manual Therapy

• The therapist should use good body mechanics
• The patient's position should be comfortable
• Therapists must respect the patient's “personal space”
• Long lever vs. short lever technique depends on the target structures
• Hand contact point should be altered based upon the relative size of target structures
• Modification of techniques may be necessary to accommodate individual therapist or patient impairments

Application

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

Technique Variables

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

Post-Mobilization

• Determine the Severity of condition
• Differentiate between mechanical vs non-mechanical pain
• Determine Level of irritability of joint
• Determine Patient dependence on PT for pain relief
• Review Pt previous experience w/ mobilization
• Is it Patient directed vs therapist directed forces?
• Review Fear avoidance beliefs vs contraindications/precautions

Contraindications to Mobilization

• Malignant lesions in the region of treatment
• 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
• 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 for HA

• Thunderclap headache (intense/hyperacute)
• New-onset HA age >50, age <10 equals a higher risk of brain tumor
• Persistent morning HA without nausea
• New onset in a patient with a history of cancer or HIV infection
• Progressive HA, worsening over weeks
• HA associated with postural changes
• Aura symptoms >1 hr, including motor weakness, differing from previous aura, or first time after starting oral contraceptives

Important General Rules for Diagnosing HA

• Each distinct type of HA that a patient has must be separately diagnosed and coded
• Patients may have different types of HA coexisting
• If a patient has more than one diagnosis, list diagnoses in order of importance to the patient
• For any particular diagnosis to be given, all listed criteria must be filled

Diagnostic HA Diary

• A diagnostic HA diary can be helpful for patients suspected of having more than one HA type
• A diary records important characteristics for each HA episode
• Improves 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 HA

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

Migraine W/O Aura

• Attacks lasting 4–72 hours when untreated
• Headache with > 2 of: unilateral location, pulsating, moderate/severe, avoidance
• During HA >1 of: nausea, photophobia, phonophobia
• Not attributable to another disorder
• More likely bilateral in children and adolescents
• Usually frontotemporal
• Occipital HA in children is rare and is a red flag

Migraine W/ Aura

• Recurrent attacks, lasting minutes
• Unilateral, reversible visual, sensory or other CNS sx
• Gradually develops, followed by HA
• Visual, sensory, speech, motor, brainstem sx
• At least one aura sx

• 3 of: gradual spread > 5 min, sequential sx, unilateral sx, with or before HA

General Comments

• Many patients with migraine with aura have migraine without aura
• Aura usually before HA
• Visual aura is most common

Tension-Type Headaches (TTH)

• Infrequent Episodic Criteria: < 1 day/month (< 12 days/year), lasting 30 min-7 days.
• Frequent Episodic Criteria: At least 10 episodes, 1-14 days/month, > 3 months.
• Both types have certain characteristics: bilateral, pressing/tightening, mild/moderate, not aggravated by activity.
• Also include no nausea/vomiting (anorexia may occur), but > 1 of photophobia or phonophobia
• Chronic Diagnostic Criteria TTH: HA occurring on > 15 days/month, for > 3 months

Cluster Headache Diagnostic Criteria

• At least 5 attacks of severe unilateral orbital, supraorbital, and/or temporal pain lasting 15-180 minutes if untreated
• Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, etc
• A sense of restlessness or agitation
• Frequency is from 1 every other day to 8/day

Secondary Types of Headache

• Another disorder is known to cause HA. HA occurs in the same timeframe as disorder. HA is reduced after successful treatment
• HA is directly linked through a causal relationship (i.e brain tumor)
• HA is minimized, resolves within 3 months of treatment or spontaneous cessation

Cervicogenic HA

• Clinical exam indicates the pain is from the cervical spine (bone, disc, soft tissue)
• Most notable results are decreased Cervical ROM (ext), and + Cervical flexion-rotation test
• Clinical and imaging show cervical spine disorder can cause the HA
• Causation shown with at least two items. HA develops during cervical disorder. The cervical disorder improves with the HA. Cervical ROM reduced with the HA. Blockading the cervical area will abolish the HA

Cervicogenic HA anatomy and management

• Convergence is the fundamental mechanism
• Efferents from two parts of the body meet at the 2nd order neuron in the SC. Pain felt, the afferent can be seen as rising in related territory
• Forehead and orbit pain are from convergence via the trigeminal and cervical afferents
• Occiput is by different cervical afferents PT management should start with patient education, soft tissue mobilization, joint mobs (cervical/thoracic), modalities, postural ex, ergonomic evaluations, and stress management

Spinal Manipulation for Chronic HA

• Systematic review of 9 RCT’s included findings for TTH, MH, and CGH Manipulation showed to be more successful than massage for CGH, as successful as pharma therapy for TTH and MH
• Systematic Review of 6 RCT’s showed that SM can be used for pain and migraine reduction The results may be preliminary. Rigorous and large RCTS are recommended for methodology
• Cervicogenic HA- The combined efforts of upper cervical and thoracic spine manipulation vs mobilization and exercise in patients with CVH are effective for chronic ha; effects can be maintained at 3 months. Orthopedic and manual PT can decrease the intensity and decreasing intensity The effects are short + long term. Includes deep cervical flexor and retractions + pt education and low level flex/ret resistive ex

Biopsychosocial model & CBT

• There is a growing amount of evidence supporting BPS model use; biomedical may encourage pt. to be passive
• The BPS model recognizes a complex mix of medical and psych variables that have an impact on the health experience. CBT wants to improve the patient’s amount of comfort over use with psych techniques. Beliefs, attitudes, and behaviour matter. A main goal is teaching specific recognition and inform about cognition effects with the pain; a common approach is exercise

Cognitive Behavioral Therapy

• Cognitions (patterns of thinking + appraisal); emotions (mood); behaviours (daily activity, response to pain); cognitive (beliefs, experience, control, distraction); emotional (cycle with depression); behaviour (inactivity, etc.)
• In CBT, parameters are typically non-specific, but treatments include pt. education, retraining, quota (exercise), and relaxation

Pain Neuroscience Education

• Explain disease and pain. Joint activity and body management are important along with pt. education; encourage the confrontations and pain
• Teaching neurobiology and physiology of pain and helping re-channel pain
• Unique for each person and requires story telling + examples and no references to the physical problem
• Coping skills training must include relaxation, scheduling, activity, distraction, and retraining
• Activity with OA can elevate a pt.'s pain; pacing is important + breaking up activity

Mental & Cognitive strategies

• Imagery (Visualizing), counting, and focus are key mental features -Cognitive= thoughts should be adaptive, with reaffirmations that help control the body

Graded exercise, sleep, and lumbar surgery:

• Intensity, duration, frequency: intensity should not be controlled and decrease sx intensity
• Poor sleep effects pain, well-being, healing, etc.(1/3 of pop.)- educate to promote sleep wellness using exercise + habits Lack of conservative approaches or images can influence choices; goals= decompress, stabilize, or reduce; dural tears, nerve and bowel are risks, treat is discectomy, laminectomy
• Procedure/ removal of spinal is minimally invasive

Surgery to stabilize the spine

• PT can do neural mobilization and ADL's; after 1 month, bending, pulling, lifting need to be limited
• With stenosis, procedure is to remove ligaments to expose + neural decompression Laminectomy + fusion for stabilization is the next procedure, with PT at 1-3 weeks: bending + lifting should be limited during these

Factors related to surgery

• Age, activity amount are important. Should start on bed mobility posture. Have them avoid lifting and twisting; the overall health is the most important factor
• Spinal graft is placed near the surgery + lumbar interbody; usually severe cases used, with screws + spacers with the spinal disc
• C spine use has access to the disc and removes muscling, for fixation + less pain + is effective, periscap and neck is focused here

Fusion types

• Pen, grasping and longitudinal
• External / internal-bone is needed + spondy

Artificial disc and kyphoplasty treatment

• Replicated discs height and normalized posture- Endurance, stability for implementation
• Kyphoplasty will reduce the issues
• A failed surgery means an inaccurate selection and pt. has issues, and 25% can’t return back; improper placement. A gradual onset means scare tissue and revision that are needed

Discectomy should avoid bending but promote walking. Kypho should have good healing and stabilization