Musculo Midterm PDF

**Musculo midterm** **Mulligan concept** Definition: The physiotherapy treatment of musculoskeletal dysfunctions has progressed towards '**corrective gymnastics**' as a complement to passive and accessory mobilization\... *Mulligan* introduces the mobilizations with movement **(MWMs)** in extremi...

**Musculo midterm** **Mulligan concept** Definition: The physiotherapy treatment of musculoskeletal dysfunctions has progressed towards '**corrective gymnastics**' as a complement to passive and accessory mobilization\... *Mulligan* introduces the mobilizations with movement **(MWMs)** in extremities and the sustained natural apophyseal glides **(SNAGs)** in spine as a continuation of this evolution ***NORMAL JOINT*** Normal motion axis. Full mobility. No pain in physiological ROM. ***JOINT WITH DYSFUNCTION*** \"As a result of acute traumatic injury or repetitive micro- trauma, joints are left in an improper position with minor positional alterations of the articular surfaces.\" ***Positional alteration*** (AP or PA, slippage and/or medial or lateral rotation. Alteration axis movement. Abnormal stress on peri- and articular structures. Pain and limitation of range of motion. Principles : It uses articular mobilizations in the direction parallel to the facet planes (Panjabi 1978) 45°- 60°-90° Usually, patient in load. MULLIGAN is an assessment and treatment technique ACCESSORY MOVEMENTS (therapist) + ACTIVE PHYSIOLOGICAL MOVEMENTS (patient) **3. PRINCIPLES OF ASSESSMENT AND TREATMENT** Identification of the comparable functional sign. Selection of the accessory movement Combination of the Accessory Mov with the Physiological Mov. Selection of the degree and orientation of the accessor mov: \- Force\ - Direction \- Joint engaged **3 CASES** 100% pain improvement = Correct joint\ Correct force applied Correct pressure direction Partially improvement = Change force Change direction There may be + joints involved. May need to be combined with another technique. No improvement or increased symptoms = Too much force applied, and the joint is already tender. Is Not "*patient Mulligan"* PILL P- Pain free.\ I- Instant result. LL- Long Lasting. 2nd acronym to remember the key points is **CROCKS:** --  C- Contra-indications (No PILL response is a contraindication) --  R - Repetitions (Only x9 for spine and x18 for peripheral on D1 ) --  O- Over pressure (usually starts on D3 ) --  C- Communication and Cooperation --  K - Knowledge (of treatment planes and pathologies) --  S- Sustain the mobilization throughout the movement, Skill, Sensibility, Subtle, Common Sense **Types of techniques** 1\. **NAGS** (Natural Apophyseal Glides) 2\. **Reverse NAGS** (Natural Apophyseal Glides) 3\. **SNAGS** (Sustained Natural Apophyseal Glides 4\. **MWMS** (Mobilization with Movements) **4. MWMS Principles of Practice :** A passive accessory joint mobilization is applied following the principles of Kaltenborn. This accessory glide must be, itself, **pain free**. The therapist must continuously monitor the patient\'s reaction to ensure no pain is recreated. The therapist investigates various combinations of parallel or perpendicular glides to find the correct treatment plane and grade of accessory movement. While sustaining the accessory glide, the patient is requested to perform the comparable sign. The comparable sign should now be significantly improved. If the therapist found an accurate one, the previously restricted and/or painful motion or activity is repeated by the patient while the therapist continues to maintain the appropriate accessory glide, during several sets/repetitions Re-evaluation is critical If not\... failure to improve the comparable sign would indicate that the therapist has not found the correct treatment plane, grade of mobilization, spinal segment or that the technique is not indicated\... The therapist should find a correct combination, level, or technique. If not, other approach will be necessary. T the treatment will be repeated on the following sessions, ALWAYS reassessing initially the basal/functional condition of the patient. The treatment will be evolved on the following sessions including: more sets/repetitions, over-pressure, tapings, and a tailored home-program **CONTRAINDICATIONS:** Patients with cognitive impairment Bone fragility Congenital joint disorders Metabolic disorders Fractures / fissures When the patient does not want to perform the movement ***Advantages :*** Immediate effects Neurophysiological effects Well tolerated\ Most joints ***Disadvantages***: Pain when incorrectly performed Patient participation **Conclusion** The Mulligan concept stands out for its rapid results and its harmlessness as it has no adverse effects. It minimizes iatrogenesis and extends its use to almost all types of patients regardless of age. **Neurological exam:** Patient symptoms:\ Palpation of the nervous system.\ Mobility (neurodynamic tests). Differentiation tests.\ Nerve conduction (neurological examination). ***Neurological exam:** Reasons to explore* Possible \"red flags\" Safety Presence of changes in nerve conduction Any acute condition, also with a traumatic origin as a complication of a neck or back pain Suspected **NS affection\ ** ***Evaluation and re-evaluation*** To have a baseline condition to compare Decision-making assistance ***Neurological exam: Goals*** ✓ Detect abnormalities in the conduction of the PNS\ ✓ Distinguish sensory or motor impairment\ ✓ Distinguish between root or peripheral nerve involvement ✓ Attempt to identify the affected root/nerve\ ✓ Attempt to identify the injured area **Neurological exam: Decision-making** Don ́t does it if it ́s not safe Do it if\... An acute process is suspected Prior to any intersegmental spinal examination that may affect the nerve roots Other situations: After functional demonstration, active and resisted movements Before the neurodynamic exam **Indications:** Upper limbs: symptoms extended beyond the shoulder Lower limb: symptoms extended beyond the gluts, groin or greater trochanter **Contraindications:** None Adaptations may be necessary Security! **Neurological exam:** Etiology Changes in nerve conduction when: Nerve injury Compression Inflammation Rupture Irritation What should it include? Muscle tone, coordination, muscle strength, reflexes, epicritical touch, vibration sensitivity *Muscle Strength* Sensory neuron, nerve root, peripheral nerve Evaluate 1 or 2 relevant muscles per level If possible, muscles innervated by a single root Tests grade 0-5 Mid-range isometric =\> Do not \"break the contraction\". Bilateral! Both sides at once, or start with the asymptomatic side XI Neck rotation ------- ------------------------------------ C1-C2 Neck flexion extension C3 Neck lateral flexion C4 Shoulder elevation C5 Shoulder abd C6 Elbow flexion C7 Elbow extension C8-T1 Thumb abduction/ fingers abduction Level Movement ----------------------- ------------------- L2-L3 psoas Hip flexion L2-L4 quadri Knee extension L4 tibialis ant Dorsal flexion L5 thumb extension Big toe extension L5-S1 Toe extension S1-S2 triceps suralis Plantar flexion S2 flexor digitorum Toe flexion *Osteotendinous reflexes assessment* Bilaterally\ Assess asymmetries Standardize protocol and technique Key muscles in upper limbs: Biceps Reflex: C5-C6 Braquioradialis Reflex: C5-C6 Triceps Reflex: C7-T1 Quadriceps/patella Reflex: L3-L4 Aquilles Reflex: S1-S2 0 No evidence ---- -------------- 1+ hypoflexia 2+ normal 3+ hyperflexion 4+ clonus *Sensitivity Assessment* Sensory neuron, nerve root, peripheral nerve Always bilateral =\> Assess Asymmetries and differences normality Standardize protocol and technique Epicritical touch and superficial pain over the same levels Normal epicritical touch =\> Not necessary to examine superficial pain If it is inconsistent, abnormal, or absent =\> Test for superficial pain ***EPICRITICAL*** Explain: What we are going to do What we expect from the patient Eyes closed! First asymptomatic side From proximal to distal Two ways: Circumferences around the limb Test \"key areas" of dermatome (distal) Do not forget overlaps *Sensitivity: Superficial pain* Just if there are any areas of inconsistent, abnormal, or absent sensitivity ***SUPERFICIAL*** Explain: What we are going to do What we expect from the patient Closed eyes! First asymptomatic side From proximal to distal Two ways: Star technique (IN-OUT or OUT-IN) Straight line C2 occipital ------- ----------------------- C3 Supraclavicular fossa C4 Acromioclavicular C5 Lateral elbow C6 thumb C7 Middle finger C8 Little finger T1/T2 Medial elbow/armpit L1 groin ------- ------------------- L2 Upper thigh L3 Anteromedial knee L4 Back foot L5 Big toe S1 Lateral foot S2 Under heel S3-S4 perineum **Non analgesic neurophysiological effects of manual therapy** **Manual Therapy (MT)** is defined as \"the set of techniques based on manual joint and soft tissue manipulation\" MT is organized on a global level through the *International Federation of Orthopedic Manipulative Physical Therapists (**IFOMPT**)* recognized as a sub-group of the *World Confederation for Physical Therapy (**WCPT**)* IFOMPT accept various methods: cyriax, osteopathy, CT massage, chiropraxy, mulligan, Maitland, McKenzie, kalternborn. It is divided in 2 main groups of techniques: 1: neuromuscular soft tissues: MTrP, muscle energy, inhibit... 2: joint techniques: mobilizations, sliding, manipulations, direct, indirect. Manipulative therapies: Osteopathic Manual Therapy (OMT), spinal manipulation (SMT) and knee joint manipulation. Mobilization therapies: *Mulligan* mobilization with movement (MWM), neural mobilization and ankle joint mobilization. Massage therapies: connective tissue massage, acupressure and conventional massage. **OMT**: mechanical, sensory, motor, psychological, pain, ANS OMT effects: mechanical: neurophysiological effects (sensory, motor, hypoalgesia, psychological, placebo.) Vegetative Mechanical Stimulus=\> neurophysiological response Bialosky's model Hypoalgesics (Bialosky's model) Bialosky's model: zone 1: clinician patient interaction 2: NS response 3: model outcomes In recent years, some studies have shown that different types of MT can affect vagal control and modify neurovegetative variables **Acting on Autonomic NS** =\> inhibitory or excitatory effect MT in cervical spine and sub-occipital release in asymptomatic patients =\> variation in HR There also seems to be a relationship between the topographical areas (cervical, dorsal, lumbar) and the autonomic response. \* Performing dorsal spinal manipulation generates increased sympathetic activity in the short term. Thus, in general, and according to some studies, there is an influence on the vegetative response depending on the area of application of the manipulation (measured in variation of HR): -- **Cervical region:** PNS activation (due to vagus nerve response) -- **Dorsal region**: SNS activation (sympathetic roots at that level) -- **Lumbar region**: PNS activation (parasympathetic activation of the parasympathetic nerves in that region). Cervical mobilization techniques generate a sympathetic excitatory effect on the region innervated by the stimulated segment =\> subjects with epicondylalgia. \- MWM techniques at the elbow result in an increase in BP, HR, and skin conductance Affects : HR, blood pressure, skin conductance, temperature, blood flow. *The MWM technique on the elbow generates similar vegetative physiological effects to those obtained with vertebral mobilizations.* **Soft tissue (myofascial) techniques** appear to facilitate the parasympathetic response following their application Interventions on gastrocnemius, biceps femoris and thoracic/cranial fascia =\> favor recovery of DBP after high intensity exercise Myofascial techniques in the cervico-scapular region =\> ANS response with increased cardiac parasympathetic activity and improved relaxation levels. Application of myofascial techniques (percussion, compression, and friction) in cranial and cervico-scapular region =\> increase of parasympathetic activity and reduction of sympathetic activity =\> improvement of relaxation levels and decrease of excitatory defense response (stress). **Neurodynamic management and treatment** Therapeutic options:\ -- Treatment of the **mechanical interface** related to patient's problem. -- Neurodynamic techniques.\ -- Self-mobilizations.\ -- Patient education. Mechanical interface management and treatment A **positive test** does not imply that neurodynamic technique should be used. Restore the functioning of the **mechanical interface.** **Increase** and make the space through which the nerve runs more **flexible.** Perform it **before** neural mobilization when it is the cause of the problem. This is an "indirect" approach These techniques can be performed: -- No neural stress/tension Produce less stress in the NS -- With neural stress/tension\ Produce more stress in the NS If the mobilization of the mechanical interface, regardless of the degree of neural stress, **reproduces symptoms**, the mechanical interface will be treated (grades I-II), evolving (grades III) when no symptoms are found. If this mobilization **does not reproduce the symptoms**, neural tension will be increased until they appear. Mobilization of the interface is then applied. If the symptom decreases, it can be used as a treatment technique. If the symptom increases, interface treatment can be performed, reducing neural tension distally Tests for diagnosis: Use of **Neurodynamic testing** Remember neural anatomy and neural tissue **mechanics** Treat the etiology first. In many cases it is necessary to treat the **mechanical interface!** Goals Reduction of mechanical forces on the nerve Dispersion of irritating substances Improve vascu Decrease sensitivity Increase mobility Decrease resistance Decrease pain Indications: **Clinical pattern of neurogenic peripheral pain** **Indicated by examination** Mobility restrictions Contraindications: Acute phases of : -- Inflammatory processes\ -- Trauma to neural or other structures. -- Metabolic diseases\ -- Surgery NS or mechanical interfaces infection Significant alterations in sensitivity. Rapidly evolving symptoms. Contraindications to passive kinesitherapy Maneuvers: sliders, tensioners, palpations Sliders: Force at one end and releasing tension at the other end Pain-free More useful to educe pain and sensitivity Tensioners Based on viscoelasticity Not about stretching the nerve Improve stiffness Performed gradually Riskier technique Principles of neural mobilization Sliders are less aggressive than tensioners Slider 2-3 Tensioners 4 Strat treatment with no pain Trat with pain only of resistance limit the movement and not the pain Don't use too much neural tension Use the lowest tension possible Watch out for muscle spasms Variations of speed, duration, education and serial neurodynamic sequences If main problem at interface treats the interface If problem more neural dominant and the interface has already been treated treat with neurodynamic techniques 2 types of disorders: irritable and non-irritable **IRRITABLE DISORDERS** Pain comes easily and takes time to go away Start with techniques away from the symptomatic area. The technique must **not be irritating**. Degrees of **amplitude** mobilization **(II)** without reproducing symptoms. When the pain is minor: -- Apply the technique in symptomatic areas.\ -- Gradually increase the **number** of repetitions.\ -- Increase **amplitude (III)\ **-- Increase **neural stress** on the NS in different sessions. -- Apply techniques with less tension if **symptoms** appear. **NON-IRRITABLE DISORDERS** Alterations occur in the nerve mechanics (there is no significant pain). Highest degree of mobilization **(III/IV)=\>** Goal is to work within the resistance Do **not** produce important undesirable **symptoms**! (pain) Include all **components** (or sensitization) to increase neural tension. No more than **10 seconds** =\> PAIN Beware of **residual pain** (local or distant). Self-treatment: Only when passive techniques have been helpful Education: patient must understand Consider possible patterns of movement and posture from ADLs that may affect the patient\'s symptoms. And make the modifications that are necessary **OMT** **Somatic dysfunction:** Altered function of related components of the somatic system (body structure) Segmental sensitization: Skeletal, articular, and myofascial structures and their related vascular, lymphatic, and neuronal elements Causes: traumas, microtraumas, postural alteration, maintained, position, temperature, inflammation Consequences: hypomobility, sensitization Hypomobility Hypermobility ------------------------- -------------------------- Joint fixation Increased joint mobility Muscle spasms hypotonia Adherences Inflammation nerve roots No spontaneous pain With spontaneous Pain on palpation Pain Positive mobility tests Negative So: dysfunctions with restrictions in flexion or extension Sprains, degenerative disc diseases, facet osteoarthritis Osteopathic diagnosis: Anamnesis Background History Reasons for consultations Static inspections Dynamic inspection Orthopedic tests Specific tests **Treatment**: structural: against injury; goal: break adherences and regulate muscle tone. ***[with manipulation]***: THRUST "passive mobilization with low amplitude and high speed, directed to a joint with limited mobility in the direction of greater injury parameter". The maximum range of motion should not exceed the joint limit 3 phases: 1- position of patient 2- put tension 3- thrust (impulse, toggle recoil, body drop, kick (Indirect technique, direct, semidirect) ***[rhythmics]***: stretching, inhibition, articulatory , muscle energy technique functional: in favor of injury: jones techniques osteopathic concepts MOTOR BARRIER: sensation of restriction due to muscular elasticity SLACK REDUCTION: putting tension in the direction of correction TISSUE-PULL: reduction of skin elasticity TORQUE: reduction of skin elasticity in a semicircular direction direct Semi-direct Indirect ------------------------- -------- ------------- ---------- reflexogenic ++++ ++ \+ specificity ++ ++ \+ Torsion of soft tissues \- ++ +++ Indications for vertebral manipulations: CERVICALSPINE Cervicalgia, headaches DORSAL SPINE Dorsalgia, costal pain, LBP LUMBAR SPINE & PELVIS LBP Contraindications of vertebral manipulations TRAUMAS, TUMORS, INFECTIONS\ INFLAMMATORYRHEUMATISM, VASCULAR, METABOLIC\ CONGENITAL, PSYCHIC Indications limb manipulation Sprains Tendinitis Traumas Contraindications Diastasis or hyperlaxity All types of fractures\ Dislocation\ Grade 3 sprains Dosage: 1 per week, 5 weeks max Complications Adverse effects 29% SERIOUS irreversible complication ***Rhythmic techniques***: [energy technique ] Monoarticular muscles Decrease tone and increase joint amplitude [Articulation technique:] Monoarticular muscles Decrease tone and increase joint amplitude Suppress adhesions [Stretching]: ligaments fascia's, tendon and muscles Decrease tone and increase joint amplitude Increase vascularization [Inhibition:] muscles Decrease tone Increase vascularization (locally) [Maintained tension:] Monoarticular muscles Relax **LUMBAR SPINE** Chronic LBP: more than 3 months or episodes for more than 6 months with some pain free periods 85% are non-specific Structures causing pain: apophyseal joints (facet joints) Intervertebral discs Nerve roots Muscles 1. Chronic discogenic LPB Multifactorial Caused by intervertebral disc (degenerative disc disorder) 40% of prevalence. Disc changes= reduced height= less cushioning capacity and movements Factors: family history Overweight Excessive tension in the lumbar area due to impact sports Prolonged sitting Weak muscles Tobacco or nicotine Deep central pain page13image3427792 24hours behavior: morning pain, symptoms more frequent in sustained positions. Relieved by nsaids and rest More evident un supine with bent knees Over the time episode lats longer and are more frequents and more intense Special questions: osteoporotic vertebral fracture, visceral pain. 2. Chronic LBP facet origin Multifactorial clinical conditions Generated by all those structures innervated by this branch of the nerve. 40-45% prevalence Medial branch of the primary dorsal ramus Fibrous capsule and meniscus= nociception Cartilage and synovial membrane= no innervation (Lot more developed in the power point, structure etc....) Factors: age, overweight, trauma, prolonged sitting (muscular inhibition) Weak lumbo-abdominal muscles Mild to moderate LBP, unilateral or bilateral, referred pain to homolateral gluteus, groin. Uncentered pain.  24h: intermittent pain during day ore pronounced getting out of bed and then decreases. Relieved by walking and in positions that reduce lumbar lordosis. Worse when standing upright. Relieved by rest and nsaids. No pain on decubitus. With time episode will be more stable. Special questions: same as discogenic but also inflammatory arthritis. 3. LBP of radicular component Radiculopathy and radicular pain are 2 different concepts: Radiculopathy: *Alteration in the function of the roots or mixed spinal nerve that gives rise to sensory, motor, or sensory-motor (decreased osteotendinous reflexes) symptoms, without necessarily being associated with pain.* Radiculopathy does not necessarily cause radicular pain and inverse as radicular pain isn't always accompanied by radiculopathy. **Dysatsthetic radicular pain**: Caused by pathophysiological changes of the radicular component, mechanical, blood perfusion or due to diffusion of inflammatory irritants from the disc =\> Neuropathic pain (ectopic impulse generator). **Truncal (trunk) radicular pain**:Caused by mechanical and/or chemical irritation of the connective membranes of the radicular component. Factors: age, overweight, joitn deformities, osteoporosis, proloned sitting, weak muscles Dull, deep pain, unilateral, more intense proximally than distally, "thightness". page35image3173968 24h: worsen with movement, no pain in decubitus. Pain relieved when no load. History: with time, episodes are more stables. Special questions: osteoporotic fractures and visceral pain. 4. Stenosis stenosis is defined as *structural narrowing of the spinal canal, lateral recesses or foramina in the lumbar region. Diagnosis is established by the presence of clinical syndrome and imaging confirmation of a narrow lumbar canal*. A canal that is narrower than usual does not necessarily cause discomfort. Stenosis is related to complex changes in the spinal column and its content. Can be age related. -congenital stenosis -acquired stenosis Symptoms appear from: mechanical compression of the neural elements by bone and soft tissues causing less blood supply and proper drainage= increased cerebrospinal fluid pressure. 3 groups: LBP, radicular (most frequent), neurogenic claudication. Factors: age (more than 65) Overweight Arterial hypertension Joint deformities such as scoliosis Degenerative processes of the spine Spondylolisthesis Dull, deep, along the nerve. Bilateral, more intense in LL than lumbar. "tightness"  24h: 3 positives out of 5: -more than 48y -Bilateral -LL pain more than lumbar -Standing pain -Relief seating Clear relief at rest Over time, episode become more acute, limiting distance patient can walk. Special questions: assess instability Urinary disorders Vascular claudication 5. Lumbar instability Abnormal mobility between vertebras. Spondylolysis: change in the ossification process of a special area of the posterior arch of the vertebrae. Overtime, this isthmus yields to the tension caused by the tension by the tendency of the upper vertebrae to slip over the lower vertebra= spondylolisthesis. Grades from 1 to 4 according displacement. 1-2 =conservative. Symptoms: mechanical LBP, hypoesthesia, paresthesia in LL, stiffness, weakness. Factors involved according to type/origin. 1. Congenital: agenesis of the superior facet joint 2. Isthmic: defect in the interarticular part 3. Degenerative: joint degeneration 4. Traumatic: by fracture, dislocation. 5. Pathological: infection, cancer, bone abnormalities. LBP radiating to LL, no clear pattern. Unilateral or bilateral. Described facet pain or radicular or stenosis depending on the situation. (All body map seen before can be possible depending patient.) 24h: pain when stand, walk, hyperextension, impact activity. If inflammatory process, constant pain. Non load bearing activities are carried out normally, except in the case of inflammatory processes. Lumbar belt can be used. Evolves to clinical tingling and even loss of strength in the legs, after walking for some distance. Special questions: osteoporotic fractures Urinary disorders Rule out type 5 (pathologic)