MOVEMENT and MANUAL THERAPY

YES! MOVEMENT and MANUAL THERAPY ROTATION EXTENSION FLEXION Main Objective * Combining Manual Therapy and Movement can effectively improve your patients quickly and empower the patient with tools for prevention of recurrences. Manual Therapy and Exercise Works Reviews * Gross et al 2010 * Bronfort et al 2012 * Chaibi and Russell 2012 * Low to moderate quality of evidence? 1

* the ease and rapidity with which a joint moves are more important factors in a movement pattern associated with pain than muscle shortness, soft tissue restrictions or limited range of motion of an adjoining joint. * Sahrmann 2012 Objectives 1. Describe the concepts of the Australian system of Manual Therapy. 2. Describe Manual Therapy examination and assessment. 3. Identify the characteristics of complementary treatment using Manual Therapy and Movement to treat a patient with neck pain. MOVEMENT DIAGNOSIS GUIDES INTERVENTION * Specific Posture Instruction * Therapeutic Exercises * Motor Control * Joint and Soft Tissue Mobilization 2

4/27/14 MOVEMENT ISN T NEW TO MANUAL THERAPY * Mechanical Diagnosis and Therapy: Robin McKenzie * Mobilization With Movements: Brian Mulligan * Muscle Energy Technique: Philip Greenman * Combined Movements: Brian Edwards * Directional bias to Joint Mobilization Vincent DeWitte 2014 Manual Therapy Is this normal mo-on? Remains flexed at T1- T2. MoFon occurs in lower neck. Pain at 3/4ths range. Anterior translafon? Is this normal mofon? Flexed at C7,T1. Increased mo-on at C6. Loss of Sagi?al Rota-on. PAIN Instructed to Chin Tuck and Roll to avoid excessive anterior transla-on in lower C/S. NO PAIN 3

4/27/14 Passive Technique: Manual Posterior neck flexion stretch AcFve Exercise: SiSng Chin Tuck / Head Nod in pafents neutral posifon. Key Concept If you passively assess joint mofon as hypomobile and perform manipulafve techniques, you may improve range of mofon and pain. But, a concomitant situafon can occur: Accessory mofon of the joint can be excessive but the physiologic mofon of the joint be less than normal. S. Sahrmann 2011 Hypomobility may not be the only impairment present at the joint contribufng to their pain. 4

Case Example of Work injury: S/P 3 months C5-7 Cervical Fusion VIDEO Pediatric nurse with neck injury 8 months ago. C/O lea neck pain, scapular pain, lea lateral arm pain and N/T constant and into the lea hand. S/P surgery 3 months ago. Aaer surgery, all arm pain was gone. Only had mild neck pain and felt weak. Began P.T. 2 months aaer surgery. All pre- surgical symptoms returned. Therapy locafon switched and sent to me. O/E: Forward head posture, decreased sagibal rotafon in neck flexion with excessive anterior translafon in lower cervical spine; scapular depression / internal rotafon. Weak intrinsic neck flexors and trapezius; dominant SCOM and scalenes; short posterior neck structures. + Neural tension sign ULTT 1 Hypomobile Facets C1-3 Lea > Right All Treatment was Movement Based in 5 visits. ObjecFvely, all objecfve assessment tests normalized in mofon and symptom- free PaFent self- assessed improvement overall = 98%. FOTO: Outcomes scores significantly improved. WHAT IS MANUAL THERAPY? APTA GUIDE TO PRACTICE * Manual therapy techniques consist of a broad group of skilled hand movements, including but not limited to mobilization and manipulation, used by the physical therapist to mobilize or manipulate soft tissues and joints for the purpose of modulating pain, increasing joint range of motion, reducing or eliminating soft tissue swelling, inflammation, or restriction, inducing relaxation, improving contractile and non-contractile tissue extensibility and improving pulmonary function. * These interventions involve a variety of techniques such as the application of graded forces. APTA GUIDE * Under Interventions: Manual Therapy Techniques * Manual Traction * Massage * Manipulation/mobilization (soft tissue and joints) * Passive range of motion * Manual lymphatic drainage 5

American Academy of Orthopedic Manual Physical Therapists A manual therapy technique comprises a continuum of skilled passive movements to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small- amplitude/high velocity therapeutic movement. Joint Mobilization / Manipulation * Non- Thrust Applied to joints & related soft tissues at varying speeds & amplitudes using physiologic or accessory motions. * Those manipulations / mobilization that do not involve thrust. * Thrust - High- velocity, low amplitude therapeutic movement within or at end range motion. OMPT DASP 2008 * OMPT is any hands- on treatment provided by the physical therapist. Treatment may include moving joints in specific directions and at different speeds to regain movement (joint mobilization and manipulation), muscle stretching, passive movements of the affected body part, or having the patient move the body part against the therapist s resistance to improve muscle activation and timing. 6

Ortho Section APTA- Terminology * Definition of spinal joint mobilization act of imparting movement actively or passively to joints or soft tissues of the spinal column. Clinical reasoning Red flags Impairment of structure Tissue mechanisms Pain mechanisms Movement dysfunction Myofascial Sensorimotor Control Articular Neurogenic Psychosocial factors Restriction in activity/participation Reprinted with permission: DeWitte V et al. Manual Therapy 2014 Lieven Danneels, Axel Beernaert, Kristof De Corte, Filip Descheemaeker, Bart Vanthillo, Damien Van Tiggelen and Barbara Cagnie. Journal of Musculoskeletal Pain 2011. Red flags Impairment of structure Tissue mechanisms Pain mechanisms Movement dysfunction Movement dysfunction Myofascial Myofascial Sensorimotor Control Sensorimotor Control Articular Articular Neurogenic Neurogenic Psychosocial factors Restriction in activity/participation Reprinted with permission: Lieven Danneels, Axel Beernaert, Kristof De Corte, Filip Descheemaeker, Bart Vanthillo, Damien Van Tiggelen and Barbara Cagnie. Journal of Musculoskeletal Pain 2011 7

What is the Australian approach in Manual Therapy? Detailed Subjective and Objective examination ASSESSMENT TECHNIQUE RE- ASSESSMENT Technique is the brainchild of ingenuity Geoff Maitland Communication Consistent with their interaction with patients, was the expert s ability to communicate a sense of commitment and caring about the patient. Jenson et al, 2000 Clinical Problem- solving * Integrate evidence, but clinical decisions are based on a systematic examination: SINS drives the process! Severity Irritability Nature Stage * PATTERN RECOGNITION Barbara Norton 1998, Duncan Reid 2013 8

DIAGNOSIS? * EVIDENCE BASED * IMPAIRMENT BASED * BASED ON S/E AND O/E * RESPONSE TO TREATMENT VIA CONTINUAL RE- ASSESSMENT. * KNOWLEDGE OF BIOMECHANICAL AND PATHOLOGICAL PROCESSES Clinical pattern recognition Acute or chronic radiculopathy Cervical discogenic Locked facet joint Cervical Spondylosis Cervical spondylotic myelopathy Anderson et al 1995, Boissonault 1995, Gifford 2001, Grieve 1981, Maitland 2005, Trott 1994, Shedid and Benzel 2007, Wolff and Levine 2002. Subsets: CPG Cleland et al 2007 1. FABQPA score < 12 points 2. Duration of current episode < 30 days (judged from the patient s self- report) 3. No symptoms extending distal to the shoulder (judged from the pain diagram) 4. Decreased cervical extension 30 degrees (measured with a bubble inclinometer) 5. Decreased T3 T5 kyphosis (identified during the postural examination) 9

Ortho Section Neck Guidelines 1) ICD 10: Cervicalgia or pain in the thoracic spine. ICF: Neck pain with mobility Deficits 2) ICD 10: Headaches or cervicocranial syndrome ICF: Neck pain with headaches. 3) ICD 10: Sprain and strain of cervical spine ICF: neck pain with movement coordination impairments 4) ICD 10: Spondylosis with radiculopathy or cervical disc disorder with radiculopathy ICF: Neck pain with radiating pain. MANUAL THERAPY Examination Intervention Re-examination * Joint thrust and non- thrust Manipulation. * Soft tissue mobilization * Traction * Neural tension gliding * Muscle energy, Myofascial Release, Craniosacral * Strain / counterstrain PROVE THE VALUE OF YOUR TECHNIQUE! * COMBINING MOVEMENT AND MANUAL * First change the patient s preferred motion strategy to an ideal kinesiological motion. * See if it changes their symptoms. 10

4/27/14 What happens next? 1. Patient improves consistently and quickly by performing precise kinesiological motion: Don t need manual techniques. 2. Patient improves but can t achieve full, precise / ideal active motion due to hypomobility and / or pain: Look for the tissue restrictions that prevent precise motion within the Movement Diagnosis. Case: Neck and arm pain 39 yo hair Stylist / colorist with c/o neck, scapular and arm pain with arm N/T and headaches. She works all day with lea arm in the air holding a secfon of hair while the right arm paints color onto hair. She appears in distress due to pain. 11

Case: Diagnostic hypothesis MANUAL * ICD 10: Cervicalgia or pain in the thoracic spine. * ICF: Neck pain with mobility Deficits * ICD: Headaches or cervicocranial syndrome * ICF: Neck pain with headaches. * ICD 10: Sprain and strain of cervical spine * ICF: neck pain with movement coordination impairments * ICD: Spondylosis with radiculopathy or cervical disc disorder with radiculopathy. * ICF: Neck pain with radiating pain. MOVEMENT * Cervical Extension/ Rotation with anterior translation. * Scapular depression and downward rotation S I N S * SEVERITY: Highly severe with constant pain, reduction in activity, worsening of symptoms, multiple levels of spinal involvement. * IRRITABILITY: Highly irritable with constant pain, radiating symptoms, constant head pain irritated by small amounts of activity. * NATURE: Movement coordination, Neural tension, cervicogenic headache, hypomobility, * STAGE: Worsening. Don t do anything to aggravate. Concentrate on Easing symptoms. If I can change the patients pain immediately by changing their preferred strategy of movement * This is what I will spend time doing because I know it will change how they move 24 hours per day. * This puts the patient in control of their pain while removing strain on the painful tissues. * Precise movement exercises lengthen short muscles / tissues and strengthen weak muscles. * Precise movement exercises change altered dominance of muscle control. 12

Treatment becomes a package deal: * Educate the patient regarding their preferred movement pattern and how to move in a strategy of precise, non- painful motion in all aggravating ADL s. * They have a new strategy of motion that is non- painful, working on muscle recruitment and motor control. It may be hard or difficult to do but is non- painful. * Provide Directional manual techniques as needed that may allow precise movement patterns to correct more quickly and exercises become easier to perform. I am a Physical Therapist Can we nurture our relationships with payers, the medical community and the public with an overall approach that encompasses all aspects of Movement as our focus. Acknowledgements * Joe Farrell * Kaiser Hayward Physical Therapy Fellowship in Advanced Orthopedic Manual Therapy * Laurie Kenny * Mary Kate McDonnell * Stephen McDavitt * Barb Norton * Shirley Sahrmann * Washington University Faculty 13