NMT 200 Physical Medicine Lab PDF

NMT 200 Physical Medicine Lab Manual Mobilization and Manipulation Instructor: Dr. Albert Iarz, ND, RMT  Week 1: Learning Outcomes By the end of this lesson, students will be able: To understand the theory behind mobilizations and spinal manipulations and their cli...

NMT 200 Physical Medicine Lab Manual Mobilization and Manipulation Instructor: Dr. Albert Iarz, ND, RMT  Week 1: Learning Outcomes By the end of this lesson, students will be able: To understand the theory behind mobilizations and spinal manipulations and their clinical applications To understand the indications and contraindications of mobilizations and manipulations To understand when to apply mobilization and manipulation techniques in a clinical setting To review general concepts and topics related to physical assessment  This lecture will be covering: A review of the OHIPMNRS model and general over-arching concepts from BMS150 (Physmed) Intro on the History & Evidence for manual therapy Beneficial effects of mobilization/manipulation Indications, clinical goals, precautions and contraindications for mobs and manips Mobilization/Manipulation grading, general techniques, joint cavitation, and reviewing controlled acts Assessment within the context of joint play, end feel, capsular patterns  OHIPMNRS A musculoskeletal assessment approach that is used to help formulate a CLINICAL IMPRESSION of the presenting concern. Also used to help IDENTIFY the root cause of the concern and thus guide treatment. Is a great approach to help figure out: if a MOBILIZATION is need, which to perform, and why As for MANIPULATION, there is a separate assessment approach that we will go over. This approach is more specific to spinal segments and the muscles that contribute to fixations/lesions  Clinical Encounter Flow – OHIPMNRS Observe (General Observations) Patient’s general appearance, posture & mobility (how do they walk into the office?) Emotional status (happy, sad) – are they comfortable? History (basic considerations) LODRFICARA with injury focus Where is the problem? Point to it exactly. When did it start? What makes it better or worse? Prior treatment or injuries? Quality of issue? (numbness, tingling, sharp, ache) Severity (scale from 0-10)? Gradual or sudden onset? What are the patient’s goals for treatment? Etc – each condition will have its own considerations Inspection (Visual, more in detail) Posture, gait, bony deformity, physical trouble with activities of daily living (ADLs) Obvious discomfort (painful expression, unable to sit comfortably, limp) Bony & soft tissues (deformity, bruising, swelling, color, sweat/ dry, scars, calluses, bunions, atrophy, ulcers) Foot wear (supportive, wear patterns on shoes, assisting devices such as orthotics or braces) Palpation – Informed Consent Must be Obtained Temperature, texture, tone, tenderness (4Ts) 360° approach of: bone, tendons, ligaments, fascia, blood vessels, nerves, lymph, viscera, AROUND painful area, above, and below it as well. Note any palpable; swelling, pain, inflammation, myospasm, scar tissue, etc Motion (AROM/PROM/RROM) Active Range of Motion (AROM) Testing Contractile and Non-Contractile Tissue (Muscle, Tendons, Ligaments, etc) Passive Range of Motion (PROM) with Over Pressure Testing Non-Contractile Tissue (Ligaments, Joint Capsule, Joint Articulation, etc) Resisted Range of Motion (RROM) Testing Contractile Tissue (Muscles, Tendons, etc) Neurovascular Screen Dermatomes Deep Tendon Reflexes Muscle strength (myotomes) Pulses, capillary refill, temperature (CMS) Referred Pain (screen adjacent areas) Myofascial Trigger Point Syndrome referral, Nerve root impingement Visceral origin Infection Psychogenic origin/overlay Special Tests /Orthopedic Tests For patient presentation After Assessment, consider more in-depth look via: Diagnostic: imaging, X-rays, U/S, CT, MRI, thermography Lab test: blood, urinalysis, biopsy, arthrocentesis etc.  A REVIEW of Orthopaedic Tests Cervical Distraction Test (Pain Relief Test) Spurling’s or Foraminal compression test Maximal foraminal compression test Valsalva Shoulder Depression Test Vertebral Artery Test Jaw Reflex Chvostek’s Test Brachial Stretch Tests/Upper Limb Tension Tests Median Nerve Dominant Radial Nerve Dominant Ulnar Nerve Dominant Thoracic Scapular protraction (winging) Elevated Arm Stress Test or “Hands-up” (ROOS) Costoclavicular test Wright’s Hyperabduction test Adson’s Test Halstead’s (Reverse Adson’s) Adam’s Sign (Scoliosis) Shoulder Cross Arm Test Active Compression Test Scapular Winging Yergason’s Test Speed’s Test Empty Can Test or Jobe’s Test Full Can Test Neer Impingement Sign Painful Arc Drop-Arm (Codman’s) Test Napoleon Sign Gerber’s (Liftoff) Test Anterior Apprehension Sign /Posterior Apprehension Sign Clunk Test Crank Test Elbow and Wrist Valgus Stress Test/Varus Stress Mill’s Test & Reverse Mill’s Test Ulnar Nerve Instability Test Tinel’s Sign (Ulnar and Median Nerve) Cozen’s Test & Reverse Cozen’s Supination Lift Test Triangular Fibrocartilage Compex (TFCC) Load Test Allen’s Test Finkelstein’s Test Phalen’s Test Pronator Teres Test Lumbar Lower Limb Tension Tests Sciatic Nerve Femoral Nerve Straight Leg Raising Test (SLR) Well Leg Raising Test (WLR) Bragard’s Test (Sign) Valsalva Kemp’s Test Bechterewis Test Belt Test Gillet’s Test/Marching Test Piriformis Test Hip Trendelenburg Test Yeoman Sign Sign of the Buttock Test Noble Compression Test Thomas Test Piriformis Length Test Pace Abduction Test Ely’s Test/Nachlas Test Faber’s Test Hibb’s Test Gaenslen’s Test Quadrant (Scouring) Test Knee Collateral Ligament Stability Test (MCL & LCL) Anterior Drawer Test Posterior Drawer Test Lachman Test McMurray’s Test Apley’s Distraction Test Apley’s Compression Test Ober’s Test (Modified) Ober’s Test (Original) Leg, Ankle, & Foot Tibial Torsion Test Dorsiflexion Test Homan’s Sign Thompson’s (Squeeze Test) Anterior Drawer Test Tinel’s Tap (Peroneal Nerve) Windlass Test  A History of Manual Therapy 400 BCE in Europe, described by Hippocrates Spinal manipulation using gravity to help treat Scoliosis Patient tied to a ladder and then inverted Practiced in many cultures to help treat a variety of MSK conditions 1656, Friar Thomas wrote a book called “The Complete Bone Setter”, describing manipulation in the treatment of spinal curvatures 18th century, it fell out of favour. Possibly due to the indiscriminate use or dangers involved in manipulating the spine, especially in those with TB (Prevalent at the time) 19th century, popularity of “Bone Setters” started to increase again. But physicians still shunned them. Chalking up success to luck By the late 19th century, bone manipulation was back and many papers and books started coming out explaining the procedure and the benefits. Fast Forward to NOW, and manipulation of bones is practiced by Osteopaths, Physiotherapists, Chiropractors, Naturopaths, Registered Massage Therapist, etc It is officially a CONTROLLED ACT under the RHPA 1991  Understanding Fundamental Concepts Mechanics: A branch of applied mathematics that looks at forces and their effects when producing motion Biomechanics: The application of mechanical laws to living structures, more specifically to the locomotor system of the human body The interrelations of the skeleton, muscles, and joint. Where BONES are the levers, LIGAMENTS form the hinges (Surround joint), and MUSCLES provide forces, moving the levers around the joint. The use of manipulative forces, takes into account the knowledge of joint mechanics and structure. It also looks into the effects that forces produce on the body. Forces: Have Directionality and Magnitude  What is Joint Mobilization A form of a non-thrust technique, typically applied within the PHYSIOLOGIC range of joint motion, but not passed the ELASTIC BARRIER. Mobilizations are passive rhythmic graded movements of controlled depth (amplitude) and rate. They may be applied with fast or slow repetitions (Oscillations) and various depth (Grades 1-4) but always low velocity Although joint mobilizations (Grades 1-4) are not commonly associated with joint cavitation, deep mobilization may induce cavitation. Movement applied singularly or repetitively within or at the physiologic range of joint motion, without imparting a thrust or impulse  Goals/Benefits of Mobilizations 1. Restore ROM of a joint 2. Pain reduction 3. Reduce muscle spasms (stretching hypertonic muscles) thus inducing relaxation 4. Stimulate synovial fluid production (joint nutrition) 5. Increase local blood flow 6. Relieve nerve compression/irritated sympathetic chain ganglia 7. Restore joint mechanics * The vibratory nature of the oscillations being applied are thought to activate sensory mechanoreceptors that may help to reduce pain and improve proprioceptive function* Clinical Indications Joint Pain/Stiffness (Kinetic Chain/Muscle Compensation) Decreased ROM during Sub-Acute/Chronic stages of injury Decreased muscular function Headaches Joint Hypomobility Myofascial Restrictions/Pain When THRUST Manipulations are contraindicated or not advisable due to harm to the patient When practitioner is unable to produce a thrusting force that is capable of producing a joint cavitation  Definitions Active ROM: Patient is moving the body part by themselves Passive ROM: Without any help from patient, the practitioner moves the joint. Due to relaxed nature of patient, this type of motion is usually greater then AROM. Physiologic Barrier: Where the END of AROM of a joint takes place due to muscle/fascial tension Elastic Limit: Felt as an elastic resistance at the end of PROM End Feel: The sensation that the practitioner feels in the joint as it reaches the end of ROM (Normal and Abnormal End Feels) Joint Play: SMALL movements that are independent of voluntary muscle contraction. Measuring less than 1/8 inch in any plane, these movements provide roll, glide, spin, and distraction combinations to aid in smooth joint motion. Paraphysiological Space - An area where there is increased movement within the joints elastic barrier after a cavitation. Does NOT pass anatomical Limit Anatomic Limit: Where anatomy limits motion of the joint. Moving beyond this limit will result in tissue damage (Sprain, Strain, Fracture) Physiological ROM of a Joint  Amplitude Grades for Oscillatory Technique Grade 1: Near beginning of range (beginning to mid) A slow, small-amplitude (rhythmic oscillations Grade 2: Within Mid Range (no stiffness or resistance) A slow, larger amplitude rhythmic oscillations Area free of stiffness or muscle spasm Grade 3: Within Mid Range to Elastic Barrier A slow, large amplitude rhythmic oscillations. Moving into stiffness or muscle spasm Grade 4: Within Deep Range to Elastic Barrier A slow, small amplitude rhythmic oscillations Stretches into stiffness of muscle spasm Grade 5: “Manipulation” CONTROLLED ACT End of Elastic Barrier Creating the paraphysiolocial space High velocity, Low amplitude THRUST Popping or Cavitation is often heard (Nitrogen gas released from synovial fluid within joint cavity) Cavitation or Cracking Noise? Manipulation procedures applied to joint structures sometimes are accompanied by a cracking noise, or cavitation. The best evidence suggests that this noise occurs as the volume oft he intra- articular space increases, and synovial fluid changes from a liquid to a gaseous state This increase in intra-articular space might explain the temporary increase in range of motion that occurs after manipulation techniques.Since the gas takes time to reabsorb, joints are not likely to crack again immediately after having been cracked Grades 1-2: Used more as warming up tissue or assessment Helps to reduce pain and irritability Grades 3-4 Used more to stretch the joint capsule and passive tissues that support and stabilize the joint Helps to increase range of motion  Generalized Graded Oscillatory Mobilization Procedure for Grade 3-4 1. Take the joint to tension (engage barrier or point of pain). This involves firm pressure until resistance is felt. However, it is important to avoid using heavy forces that might create reactive muscle spasm. 2. Start repetitively and rhythmically mobilize until a release of resistance occurs. Averaging about 120 oscillations per minute for no more than 60 seconds. 3. Continue mobilizing until motion is normal (average is 3 to 10 mobilizations sessions). 4. Stay just short of reproduction of the symptoms, barely engaging the point of pain and backing away. **If the amplitude is too small, the procedure will be less effective; if the amplitude is too great (going too far into the painful area), the symptoms will be aggravated.** Osteokinematic Movements: Refers to movements of bony levers in the body that are possible in anatomical planes Arthrokinematics Movements Refers to movements that occur within the joint or between articular surfaces (Glides, Rolls, Spins) Types of Joint Motion 1. Glide or Slide or Translational: When 1 bones articular surface slides on another (Carpal bones slide in relation to eachother when the wrist flexes and extends) 2. Roll: When 1 bones articular surface roots on another (Tibia rolling on fetus as knee flexes or extends) 3. Spin or Rotational: When the bone moves but the mechanical axis remains stationary (when the humerus rotates or spins during external or internal rotation of the shoulder) These motions occur simultaneously in most joints in the body. Types of Mobilizations 1. Antero-Posterior Glide (AP Glide) 2. Posterior-Anterior Glide (PA Glide) 3. Inferior Glide 4. Superior Glide 5. Medial Glide 6. Lateral Glide It’s all about the starting position for your AP or PA glides in relation to anatomy. Then it’s what direction are you mobilizing in.  What is a Joint Manipulation (Grade 5 Mobilization) A thrust technique, that takes the joint PAST its physiological ROM without exceeding the anatomical limit. Characterized by a Low-Amplitude, High-Velocity thrust usually producing an audible articular crack/pop/cavitation. A CONTROLLED ACT THE RHPA STATES THAT: Moving the joints of the spine beyond the individuals usual physiological range of motion using a FAST, LOW amplitude thrust is a CONTROLLED ACT A controlled act means that in order to perform any of the acts as treatment, you MUST 1. Be a member in good standing, of a REGULATED HEALTH COLLEGE 2. That regulated health profession must have, within its SCOPE of PRACTICE that specific act  Within a Naturopath’s Scope of Practice CONO: Standard of Practice: Manipulation Introduction The intent of this standard is to advise Members of the requirements to perform manipulation safely, effectively, and competently. Performing manipulation is a controlled act: “Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust”. Members are authorized to perform manipulation under the Naturopathy Act, 2007, S.O. 2007, CHAPTER 10, Sched. P, s. 4.1. 1. Competency The Member has the knowledge, skill and judgment necessary to perform manipulation safely, ethically, and competently. 2. Assessment and Treatment The Member conducts an assessment and formulates a diagnosis based on subjective and objective findings prior to performing manipulation. The Member ensures timely reassessment of the patient’s progress and response to treatment. The College of Naturopaths of Ontario Performance Indicators In addition to meeting the Standard of Practice for Performing Authorized Acts, the Member: assesses the patient for contraindications prior to performing manipulation; performs manipulation for therapeutic purposes when it is clinically relevant. 3. Contraindications to Manipulation The Member is knowledgeable about absolute and relative contraindications to manipulation and is aware that special care is warranted when considering manipulation of the cervical spine. Performance Indicators The Member: exercises due diligence and errs on the side of patient safety when a patient presents with a condition where caution is warranted before performing manipulation screens patients for Contraindications to Cervical Manipulation When a patient presents with a relative contraindication, the Member uses professional judgment to determine whether manipulation is appropriate and modifies the procedure as necessary. The Member does not perform manipulation if: the patient has or may have one or more of the contraindications listed in the General Regulation; (see CONO’s Manipulation Contraindications Guideline) the Member is in doubt about the accuracy of the patient’s health status or health history with respect to any of the contraindications listed in the General Regulation; or (see CONO’s Manipulation Contraindications Guideline) any of the provisions regarding mandatory referral of the patient, listed in the General Regulation, apply. 4. Record Keeping The Member maintains records specific to the manipulation. Performance Indicators In addition to the College’s Standard of Practice for Record Keeping, the Member will document in the patient chart: all levels of the spine adjusted using high velocity, low amplitude thrust including laterality and any or all other joints adjusted or mobilized; treatment that was commenced but not completed, including the reasons for non-completion; specifics of all adjunctive therapy used with manipulation (e.g., ultrasound, interferential current).  Therapeutic Effects of Manipulation Reduce joint malpositioning Induce local muscle relaxation Break soft tissue adhesions Stretch ligaments and joint capsules Decrease hypo-mobility of joint Pain reduction (Widely Accepted evidence based) Reduce muscle spasms (stretching hypertonic muscles) thus inducing relaxation Stimulate synovial fluid production (joint nutrition) Restore ROM of a joint Increase local blood flow Relieve nerve compression/irritated sympathetic chain ganglia Restore joint mechanics/Muscle strength/Posture Clinical Indications Joint Pain/Stiffness (Kinetic Chain/Muscle Compensation) Decreased ROM during Sub-Acute/Chronic stages of injury Decreased muscular function Headaches Joint Hypomobility Myofascial Restrictions/Pain  Potential NEGATIVE Effects Adequate Reactions (Onset 6-12 hours) Localized soreness Minor brusing Headaches Tiredness Less than 2 days duration Exceeding Reactions (Onset 6-12 hours) Objective worsening of signs and symptoms Interferes with work Excessive bruising or soreness Last more than 2 days in duration  Relative Contraindication A problem/condition that is identified before the treatment is provided, that unless modified, the application of the treatment has potential to cause harm to patient Absolute Contraindication A problem/condition that is identified before the treatment is provided, and WILL cause potential harm if the treatment is applied. Thus treatment is NOT applied  More Absolute Contraindications Infection/Inflammation of the meninges (Meningitis) Cervical Contraindications Vertigo Dizziness Nausea Vomitting Nystagamus Numbness Diplopia/Vision disturbances Dysarthria Dysphagia Ataxia History of Stroke, MI Cerebral Artery insufficiency  Joint Assessment What is Range of Motion? The motion that is allowed by the shape of the joint and the soft tissue surrounding it Is able to occur in all planes of movement: Flexion, Extension, Abduction, Adduction, Internal, and External Rotation The distance that a muscle can maximally shorten (Concentric Contraction) to the point of maximal lengthening (Eccentric Contraction End Feel of a Joint Normal Bone to Bone: Painless end ROM that is hard (Elbow Extension) Ligamentous: Painless end ROM that is hard. Limited by ligamentous tension. (Knee Extension) Tissue Stretch: Hard or firm feeling that is near the end of ROM but limited by muscle or fascial tension (Cervical Lateral Flexion) Soft Tissue Approximation: Soft or squeezing feeling that is near the end of ROM but limited by soft tissue compression (Elbow Flexion) End Feel of a Joint Abnormal Bone to Bone: Painful with a hard feeling at the end or near the end of ROM (Osteophytes, etc) Muscle Spasm: A guarded or pulling feeling that is protective of injured area (Trauma or instability) Capsular: Boggy end feel or firm with decreased ROM and pain (Swelling, edema, adhesions, adhesive capsulitis, etc) Springy Block: A rebound effect/Bouncy or springy in a non capsular pattern (Meniscal tears/derangement) Empty: Lack of a normal end resistance. Past anatomical barrier (Hyper-mobility, ligament rupture, etc)  PAR-Q Procedures: Explaining the treatment that will be provided. In our case, this would pertain to mobilizations and manipulations Viable Alternatives: Other treatments that would still benefit the patients presenting concern. Material Risks: If any, risks to the treatments and common side effects such as soreness, cavitation, etc. Questions: This allows the patient to ask questions pertaining to that specific procedure. Can be used as informed consent, specifically to the treatment being explained under PROCEDURES. This is not informed consent for every treatment or physical test that the practitioner would like to do.  Week 1 Practical Session In these weekly practical sessions, we will be going through manual manipulation techniques, from a grade 1 mobilization all the way to a grade 5 manipulation. We will be focusing on specific segments of the spine, learning how to apply manual manipulation to that segment, and then moving on to the next segment. This weeks session is more focused on review and manual practice exercises to help awaken or refine your skills before we start next session with mobilizations. A practitioner needs to be COMPETENT AND CONFIDENT in their ability and skills to manual manipulate their patients. This not only makes the treatment successful, but it also can be seen by your patients and they will respond positively. Manual manipulation skills are best learned with practice repetition. So please don’t worry if you feel uncomfortable at first, or are unsure how to even start. With repeated practice, you will become a competent and confident practitioner in physical medicine.  Preparation/Practice Techniques Mental Visualization of anatomical structures being treated/ contacted and applying force to. This means, ANATOMY. We will go through relevant anatomy as the course progresses for each treatment Learn to RELAX. Both the patient and the practitioner need to be relaxed in order for the treatment to be successful. This will include instructing your patient on a breathing technique, to help them focus on their breath vs the technique. Appropriate SET-UP of the targeted joint. Manual manipulation is mostly set-up with the thrust or non-thrust only accounting for a minimal amount of the overall treatment. Appropriate CONTACT points and Centre of Gravity. A practitioners centre of gravity is usually close to the points of contact. Set Up Tension is key. Do not release this tension when going into your manipulation. Breathing Technique during Manipulation: Get your patient, once set up is complete, to take a deep breath in and then let it all the way out. Near the end of exhalation, the practitioner completes the thrust. Posture is everything. Be aware of your posture and do not compromise it based on your table or patient. Always adjust the table to match your best positioning. Points of Contact Pisiform (ulnar side of palm) Hypothenar/Thenar Distal/Middle/Proximal Phalanges Creases Heel of palm (Not Labeled) Thenar and Hypothenar lines meet in the middle 5th Metacarpal (Not Labeled) - Ulnar side of Palm Web of Thumb (Not Labeled)  Case #1 JD is a 30 year old female with complaints of; bilateral neck pain, left shoulder and wrist pain, and bilateral mid back pain. She was in a car accident 5 years ago and suffered from whiplash, a fractured wrist, and a rotator cuff tear. She had been to rehab and did well. She felt a lot better and has been back to her doctor and they have told her that everything has healed. However, she is still experience chronic pain/stiffness in those areas, even after 5 years. Please perform an OHIPMNRS assessment on your patient using the following results as your guide. Observation: When looking at her posture, you notice rounder shoulders, a minor scoliosis in her upper T-Spine, and a slight leaning to her left side. She does NOT have an abnormal gait. History: She was in a car accident 5 years ago and suffered multiple injuries. They are all healed according to imaging. Inspection: There is no visible; edema, erythema, contusions, or signs of a wound over her neck, mid back, shoulder, or wrist. Palpation: Feeling for temperature, it is consistent throughout without feeling hot in any area. With Tone, you notice hypertonicity of her thoracic erector muscles bilaterally, with tenderness over her Levator Scapulae (Near Attachment at the scap) and over her rhomboids, again bilaterally. She feels tenderness over her anterior shoulder and tenderness over her wrist extensors. With Ranges of Motion, you notice the following; AROM: Neck: Limited but not painful flexion and extension Shoulder: Pain over anterior shoulder/AC joint area, on abduction above 90 Degrees and with internal rotation Wrist: Limited but not painful flexion and extension PROM Neck: Restriction felt with flexion Shoulder: ALL WNL Wrist: Restriction felt with flexion and extension RROM Neck: Pain on extension Shoulder: Normal strength without pain Wrist: Normal strength without pain Neurovascular Assessment Dermatomes: All upper dermatomes intact Myotomes: All upper myotomes graded at a 5 (normal) DTR’s: All upper DTR’s were a 2+ (normal) Special Orthopaedic Tests: (+) BILATERALLY: Shoulder Depression Test (Stretched Side was painful), (+) Left Shoulder: Empty Can Test,Full Can Test, Neer Impingement Sign, Painful Arc, Drop-Arm (Codman’s) Test, Napoleon Sign, Gerber’s (Liftoff) Test (+) Left Wrist: Pronator Teres Test (-) BILATERALLY: Distraction Test, Spurling’s, Maximal foraminal compression test, Valsalva, Vertebral Artery Test, Brachial Stretch Tests/Upper Limb Tension Tests (Median Nerve Dominant, Radial Nerve Dominant, Ulnar Nerve Dominant) (-) LEFT SHOULDER: Cross Arm Test, Active Compression Test, Scapular Winging, Yergason’s Test, Speed’s Test, Anterior Apprehension Sign /Posterior Apprehension Sign, Clunk Test (-) Left Wrist: Tinel’s Sign (Ulnar and Median Nerve), Cozen’s Test & Reverse Cozen’s, Supination Lift Test, Triangular Fibrocartilage Compex (TFCC) Load Test, Allen’s Test, Finkelstein’s Test, Phalen’s Test Clinical Impression: 1. Myofascial Restrictions causing pain in her neck, with trapezius and levator scap hypertonicity with associated trigger points over her rhomboids. All caused from previous whiplash injury, minor scoliosis, and consistent poor posture 2. Supraspinatus/Subscapularis tendonitis/tear, due to previous injury, poor posture, and muscle imbalances 3. Pronator Teres syndrome due to overuse of pronator teres. Possibly due to overcompensation as a result of hypertonic wrist extensors Please Practice the Following Skills with your patient as treatment 1. Ensure all ROM were completed for all joints in case, with a specific focus on PROM with applied overpressure, noting the feelings of what is normal for each joint. Neck Normal Tissue Stretch: Lateral Flexion, Extension, Rotation, Flexion Soft Tissue Approximation: Flexion (Can be both) Shoulder Normal Ligamentous: Abduction Tissue Stretch: Abduction (Can be both), Adduction, Flexion, Extension, External/Internal Rotation Elbow NormalNormal Bone to Bone: Elbow Extension Ligamentous: Elbow Extension (Can be both) Tissue Stretch: Pronation/Supination Soft Tissue Approximation: Flexion Wrist NormalNormal Bone to Bone: Radial/Ulnar Deviation Ligamentous: Radial/Ulnar Deviation (Can be both) Tissue Stretch: Flexion, Extension Perform: 2. Mild Traction of (TA Will demonstrate) A. Neck B. Shoulder C. Wrist 3. Stretching of (Use notes below) D. Neck E. Shoulder F. Wrist ASSISTED SCALENE STRETCH With the pa)ent supine. Place your right hand on the pa)ent's head just above her le: ear. Place your le: hand against the le: shoulder to anchor it in place. Laterally flex the head and neck to the right as far as possible without pain. The pa)ent then relaxes and breathes in. While the pa)ent exhales, bring the right ear closer to the right shoulder, being sure to keep the nose pointed directly at the ceiling. ASSISTED LEVATOR SCAPULAE STRETCH (PLEASE TRY SUPINE) The patient sits comfortably on a chair keeping the back lengthened. Tuck the chin to the chest and rotate the head to the right about 45 degrees. Stand behind the pa)ent, place one hand on the back of the head and the other at the top of the le: scapula. The patient relaxes and breathes in, on exhale; tuck the chin closer to the chest to deepen the stretch on the levator. ASSISTED UPPER TRAPEZIUS STRETCH The pa)ent is supine. Rotate the head to the right as far as possible without pain while tucking in the chin. Place your le: hand at the pa)ent's occiput, fingers poin)ng toward the ceiling. Place your right hand on the le: shoulder. The pa)ent relaxes and breathes in. As he/she exhales, rotate the head farther to the right, tucking the chin more (if possible), and pushing the shoulder farther away from the head. ASSISTED SCM STRETCH The pa)ent is supine. Keeping the neck lengthened rotate the head to the le: as far as possible without pain. Cradle the pa)ent's head in your le: hand, place your right hand just above the right ear. The pa)ent relaxes and breathes in. As she exhales, rotate the head farther to the left. Assisted Subscapularis Stretch The patient is supine with the shoulder abducted to 90 degrees and the elbow flexed to 90 degrees. The arm is externally rotated as far as possible, with the upper arm resting completely on the table to avoid recruiting other muscles. Place one hand under the patient's elbow and the other hand over the wrist. The patient relaxes and inhales deeply. On exhale, externally rotate the humerus. Hold for 30-60 seconds Assisted Infraspinatus and Teres Minor Stretch The patient lies prone with the shoulder abducted to 90 degrees and the elbow flexed to 90 degrees. The arm is internally rotated as far as possible, and the upper arm is resting completely on the table to avoid recruiting extra muscles. Place one hand over the patient's elbow and the other hand under the wrist. The patient relaxes and inhales deeply. On exhale, internally rotate the humerus farther. Hold for 30-60 seconds Assisted Middle Trapezius and Rhomboids Stretch With the patient in supine the left arm flexed at the elbow, bring the humerus across the chest as far as possible. Stand facing the left side. Reach under the back so that your right fingers grasp its medial border of the scapula. The patient relaxes and breathes in. On exhale pull the arm farther across the chest protracting the scapula. Hold for 30-60 seconds Assisted Pectoralis Major Stretch With the patient prone the right arm is abducted to 90 degrees and externally rotated, with the elbow bent to 90 degrees. Standing at the right side of the table support the patient's right arm from the elbow to the hand using your right forearm and hand. Lift the right arm toward the ceiling as high as possible, keeping the forearm horizontal. The patient relaxes and breathes in. On exhale lift the arm higher, keeping the forearm horizontal and the sternum on the table to prevent trunk rotation. Hold for 30-60 seconds Assisted Pectoralis Minor Stretch With the patient supine on the table. Stand on the left side and hold the patient's left hand in your left hand, allowing the upper arm to rest at the side, on the table. Place the fleshy part of your right palm on the anterior shoulder. The patient relaxes and breathes in. On exhale ask the patient to pull the shoulder down while you assist. Hold for 30-60 seconds Assisted Serratus Anterior The patient is prone on the table with arms resting at the sides. Stand at the head of the table and place the pads of your fingers against the lateral border of the right scapula. Passively retract the scapula. The patient relaxes and breathes in. On exhales pull her shoulder blade closer to the spine. Hold for 30-60 seconds Assisted Biceps Brachii Stretch The patient lies supine with the left shoulder at the edge of the table to ensure full range of motion of the shoulder. The left elbow is straight, and the shoulder is extended as far as possible. The forearm is in neutral, neither supinated nor pronated (the palm faces inward). Place your right hand against the left forearm use your left hand to stabilize the shoulder. The patient relaxes and inhales deeply. On exhale, extend the arm deepening the biceps stretch. Hold for 30-60 seconds Assisted Triceps Stretch The patient is prone, with the head resting in the face cradle or turned to the side. Flex the right shoulder and elbow bringing the hand toward the shoulder blade, keeping her arm as close to her ear as possible. Place your hand against the posterior elbow, the patient relaxes and breathes in. On exhale, deepen the triceps stretch by elevating the elbow Hold for 30-60 seconds Assisted Wrist and Finger Flexor Stretch The patient is supine, with the right elbow straight, arm resting on the table if possible, and his wrist and fingers extended as far as possible. Place the palm and fingers of your left hand over the palm and fingers of the patient's right hand. Your other hand stabilizes the wrist and forearm. The patient relaxes and breathes in. On exhale, deepen the wrist flexion by extending the wrist Hold for 30-60 seconds Wrist and Finger Extensor Stretch The patient is supine, with the right elbow straight, arm resting on the table, and wrist and fingers flexed as far as possible. Wrap your right hand over the stretcher's fist. Your other hand stabilizes the wrist and forearm. The patient relaxes and breathes in. On exhale, deepen the flexor stretch by flexing the wrist Hold for 30-60 seconds Forearm Supinator Stretch The patient is supine with the right upper arm resting at the side, elbow flexed to about 90 degrees. Pronate the right forearm and hand (palm turns down) as far as possible. Support the forearm with one hand, and the wrist and hand with the other, being careful to keep the wrist in neutral, neither flexed nor extended, to avoid undue stress on the joint. The patient relaxes and breathes in. On exhale, deepen the supinator stretch by increasing pronation Hold for 30-60 seconds Forearm Pronator Stretch This stretch is used to increase range of motion in supination The patient is supine with the right upper arm resting at the side, elbow flexed to about 90 degrees Supinate as far as possible. Stand facing the patient; support the forearm with your right hand, and with your left, grasp the hand and wrist. The patient relaxes and breathes in. On exhale, deepen the stretch of the pronators by increasing supination Hold for 30-60 seconds  Case #2 AG is a 20 year old male with complaints of; a sore right lower back, shooting pain going down his right leg, and right ankle stiffness. He reveals that he sprained his right ankle about 3 months ago, but just hasn’t felt right since. He’s had no other injuries and the pain in his lower back started about 3 weeks ago. Please perform an OHIPMNRS assessment on your patient using the following results as your guide. Observation: When looking at his posture, you notice that it’s very good. Upon a gait analysis, you notice that he is favouring his left leg a bit and that his right foot is not dorsiflexing as high as it should. History: He did see a physio for his ankle and they told him it was a high ankle sprain (damage to the tib/fib area of the ankle) and that he is altering his gait to compensate for the pain. After it healed though, he picked up ice hockey and has been playing 2 games per week for the last 3 weeks. Inspection: There is no visible; edema, excoriations, erythema, contusions, or signs of a wound over his lower back, glutes, hamstrings, quads. However, there is slight edema over the anterior ankle/dorsum of foot. Palpation: Feeling for temperature, it is consistent throughout without feeling hot in any area. With Tone, you notice hypertonicity of his right glute med and piriformis with tenderness over his right SI joint and the dorsum of his foot. With Ranges of Motion, you notice the following; AROM: Lumbar: Limited and slightly painful in extension Hip: Limited in external rotation and pain in the SI upon flexion Ankle: Limited in all ranges but not painful PROM Lumbar: Limited and slightly painful in extension Hip: Limited in external rotation/internal rotation Ankle: Limited in all ranges but not painful RROM Lumbar: WNL Hip: Painful with external rotation Ankle: WNL Neurovascular Assessment Dermatomes: All lower dermatomes intact Myotomes: All lower myotomes graded at a 5 (normal) DTR’s: All lower DTR’s were a 2+ (normal) Special Orthopaedic Tests: (+) Lower Back/Right Side: Lower Limb Tension Tests (Sciatic Nerve), Gillet’s Test/Marching Test, Piriformis Test, Belt Test (+) Right Hip: Trendelenburg Test (standing of right leg), Piriformis Length Test, Pace Abduction Test, Faber’s Test (Over Right SI), Hibb’s Test, Gaenslen’s Test (Right SI) (+) Right Ankle: Tibial Torsion Test, Dorsiflexion Test, (-)Lower Back/Right Side: Lower Limb Tension Tests(Femoral Nerve), Straight Leg Raising Test (SLR), Well Leg Raising Test (WLR), Bragard’s Test (Sign), Valsalva, Kemp’s Test, Bechterewis Test, (-) Right Hip: Yeoman Sign, Sign of the Buttock Test, Noble Compression Test, Thomas Test, Ely’s Test/Nachlas Test, Quadrant (Scouring) Test (-) Right Ankle: Homan’s Sign, Thompson’s (Squeeze Test), Anterior Drawer Test, Tinel’s Tap (Peroneal Nerve), Windlass Test  Clinical Impression: 1. SI Joint Dysfunction or Sacroiliaciitis, possibly due to hypertonic muscle attachments 2. Piriformis Syndrome causing the shooting pain and sciatic nerve irritation 3. Stiff ankle due to previous injury where scar tissue/improper rehab may have occurred, thus making the area around the ankle tighter/protective. Decreased ROM, especially in dorsiflexion. Please Practice the Following Skills with your patient as treatment 1. Ensure all ROM were completed for all joints in case, with a specific focus on PROM with applied overpressure, noting the feelings of what is normal for each joint. Lumbar Normal Tissue Stretch: Lateral Flexion, Extension, Flexion, Rotation Soft Tissue Approximation: Flexion Hip Normal Tissue Stretch: Lateral Flexion, Extension, Flexion, Rotation Ankle NormalNormal Tissue Stretch: Dorsiflexion, Plantar Flexion, inversion, eversion 2. Mild Traction of (TA Will demonstrate) G. Hip H. Ankle 3. Stretching of (Use notes below) I. Lumbar J. Hip K. Ankle Assisted Stretches Trunk Rotators The patient is seated on the table, with knees bent and legs hanging over the side Keeping the spine lengthened, the patient twists to the right as far as possible, keeping the nose in alignment with the sternum Reach under the patient's right arm to place your right hand on the anterior shoulder. Place your left hand on the left scapula, near the inferomedial border. The patient relaxes and breathes in. On exhale take the patient farther in rotation. Hold for 30-60 seconds Quadratus Lumborum Stretch The patient is lying on the left side, with the back at the edge of the table and the right leg hyperextended and hanging over the edge of the table. The left leg is bent and as close to his chest as possible. The patient reaches his right arm up over the head. Stand behind the patient, cross your arms and place your left hand against the right iliac crest; your right hand is spread wide and placed on the lateral aspect of the rib cage Ask the patient to relax take and take a deep breath. On exhale bring the patients foot closer to the floor increasing the QL stretch Hold for 30-60 seconds Latissimus Dorsi Stretch The patient is prone on the table, arms outstretched and externally rotated Using a stable front-to-back lunge stance, grasp the patients's arms or wrists securely. The patients takes a deep breath and on exhale, take the arms farther forward toward the ceiling, and externally rotate the arms more. Hold for 30- 60 seconds Gluteus Maximus Stretch With the patient supine lift the leg with the knee bent towards the chest Both hips stay flat on the table to ensure that the muscle is being stretched and not just rotating the pelvis. Assist to passively move the thigh closer to the chest until a stretch is felt in the gluteus maximus or you reach the end of the comfortable range of motion. Patient relaxes and takes a deep breath in On exhale take the thigh closer to the chest, increasing the stretch on the gluteus maximus Stretch Piriformis The patient is supine, with the left hip and knee flexed to 90; the right leg rests on the table. Rotate the left thigh laterally by bringing the left foot closer to the right shoulder. Place one hand on the lateral knee and the other hand on the lateral ankle to find the leg position that begins to stretch the piriformis. Patient relaxes and takes a deep breath On exhale increase the stretch on the piriformis  Hip Abductor Stretch The patient is side-lying at the edge of the table, top leg hyperextended and hanging over the edge of the table; the bottom leg is bent at the knee as close to the chest as possible The hips are vertically on top of each other. Bring the leg toward the floor, lengthening the abductors to their end range. Standing behind the patient stabilize the hip with one hand, placing your other hand across the lateral aspect of knee joint Patient relaxes and takes a deep inhale On exhale bring the top leg closer to the floor. Hip Adductor Stretch The patient is supine, both hips flat on the table Without arching the back, abducts the right hip as far as possible, keeping the knee straight and the kneecap pointed toward the ceiling Stand at the right side of the table, between the table and the patient's leg Support the lower leg with your left hand and place your right hand across the medial aspect of the knee. The patient relaxes and inhales deeply. On exhale abduct the hip farther deepening the stretch of the adductors. Psoas Stretch The patient lies prone. Lift the leg off the table as high as possible, with the knee bent. Support the leg just above the knee to provide resistance to the contraction of the iliopsoas The patient relaxes and takes a deep breath On exhale take the hip into further extension Gastrocnemius Stretch Prone on the table, with feet hanging over the edge Dorsiflex one foot as far as possible. Stand at the end of the table and place the palm of your hand against the patient's foot. Use your thigh to support your hand, being sure to maintain good posture. Patient relaxes and inhales deeply while maintaining the foot in the starting position. On exhale, ease into the gastrocnemius stretch. Hold for 30-60 seconds Soleus Stretch Prone on the table, with one knee flexed to 90 degrees. Dorsiflex the foot as far as possible. Support the bent leg with one hand and wrap your other hand around the heel with your forearm resting against the sole of the foot. Patient relaxes and inhales deeply while maintaining the foot in the starting position. On exhale, ease into the soleus stretch. Hold for 30-60 seconds Tibialis Anterior Stretch Supine on the table, plantarflex the right ankle Cup the right heel with your left hand and hold the top of the right foot with your right hand The patient relaxes and inhale deeply, while maintaining the foot in the starting position. On exhales, ease into the tibialis anterior stretch. Hold for 30-60 seconds Peroneal Stretch (Evertors) Supine on the table invert the right ankle The ankle is kept in neutral relative to dorsiflexion or plantarflexion. Grasp the lower leg with your right hand to stabilize it, and place your left hand against the lateral side of the right foot Patient relaxes and inhales deeply, while maintaining the foot in the starting position. On exhale, ease into the peroneal stretch Tibialis Posterior Stretch (Invertor) Supine on the table evert the right ankle The ankle is kept in neutral relative to dorsiflexion or plantarfiexion. Grasp the lower leg with your left hand to stabilize it, and place your right hand against the medial side of the patient's right foot. The patient relaxes and inhales deeply, while maintaining the foot in the starting position. On exhale, ease into the tibialis posterior stretch. Hold for 30-60 seconds