This pa ge inte ntiona lly le ft bla nk
Ma it la n d ’s P e r ip h e r a l Ma n ip u la t io n
This bo o k is de dic ate d to the me mo ry o f Ge o ff and Anne Maitland and the le g ac y the y have le ft fo r us to nurture and e vo lve
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Ma it la n d ’s P e r ip h e r a l Ma n ip u la t io n Manag e me nt o f Ne uro mus c ulo s ke le tal Dis o rde rs Vo lume 2 FIFTH EDITIO N
Ed ite d b y
Elly Hengeveld MSc BPT OMTsvomp Clin Spec sioswiss/MSK IMTA Member Oberentfelden, Switzerland
Kevin Banks BA MMACP MCSP SRP IMTA Member Chartered Physiotherapist, Rotherham, UK C o n s u ltin g Ed ito r
Matthew Newton HPC Reg, MCSP, MMACP, MIMTA Teacher, International Maitland Teachers’ Association Orthopaedic Physiotherapy Practitioner, Doncaster, UK
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2014
© 2014 Elsevier Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/ permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). First edition 1970 Second edition 1977 Third edition 1991 Fourth edition 2005 Fifth edition 2014 ISBN
978-0-7020-4067-2
British Library Cataloguing in Publication D ata A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication D ata A catalog record for this book is available from the Library of Congress N otices Knowledge and best practice in this eld are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identi ed, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/ or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
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Contents Contributors .
vi
Biography.–.Geoffrey.Douglas.Maitland .
vii
Preface. .
xi
Acknowledgements..
xiii
In.Memoriam:.Kevin.Banks.(1959–2012)..
xiv
Glossary..
xv
1 The Ma itla nd Conc e p t a s a c linic a l p ra c tic e fra me work for ne uromus c ulos ke le ta l d is ord e rs Kevin Banks and Elly Hengeveld
1
2 The Ma itla nd Conc e p t: Evid e nc e -b a s e d p ra c tic e a nd the move me nt s c ie nc e s Elly Hengeveld
66
3 Ma na ge me nt of c ra nioma nd ib ula r d is ord e rs John Langendoen
88
4 Ma na ge me nt of s hould e r a nd s hould e r gird le d is ord e rs Phillip Ackerm an and Matthew Newton
142
5 Ma na ge me nt of e lb ow d is ord e rs Toby Hall and Kim Robinson
261
6 Ma na ge me nt of wris t a nd ha nd d is ord e rs Pierre Jeangros
324
7 Ma na ge me nt of hip d is ord e rs Di Addison
375
8 Ma na ge me nt of kne e d is ord e rs Gerti Bucher-Dollenz and Elly Hengeveld
450
9 Ma na ge me nt of foot a nd a nkle d is ord e rs Jukka Kangas
512
Ap p e nd ix 1 Ap p e nd ix 2 Index. .
Se lf-ma na ge me nt s tra te gie s : Comp lia nc e a nd b e ha vioura l c ha nge
558
Re c ord ing
565 577 v
Contributors Phillip Ac ke rman MSc HPC Reg MCSP MMACP PGDip (Inj Ther)
Pie rre Je ang ro s MTs vomp DVMT MACP Senior Teacher IMTA, Lutry, Switzerland
Orthopaedic Physiotherapy Practitioner, Doncaster, UK Di Addis o n BPhty(Hons ) PG Dip (Adv Manip Phys io) SEVB1 OMTs vomp
Senior Teacher IMTA; Principal Muscle Balance Teacher, Physiotherapie Hinterm Bahnhof, Affoltern, Switzerland Ke vin Banks BA MMACP MCSP SRP IMTA Member Chartered Physiotherapist, Rotherham, UK Ge rti Buc he r-Do lle nz MAS (Phys iotherapy and Educational
Jukka Kang as MSc (Rehab) PT Specialist Manipulative Physiotherapist, IMTA Teacher(cand); Fysioterapia-konsultit FTK Oy, Helsinki, Finland Jo hn Lang e ndo e n MSc (Pain Management) OMT BPT Member of the International Maitland Teachers’ Association, Interdisciplinary Forum for Cranio-Facial Syndromes, International Kinematic Taping Academy – IMTA, IFCFS, IKTA), Kempten, Germany
Des ign) OMT
Senior Teacher IMTA, Orthopaedic Physiotherapy Practitioner, Heiligkreuz, Switzerland
Matthe w Ne wto n Grad As s oc Phys MCSP MMACP PG Dip (Inj Ther) HPC Reg IMTA Member
Orthopaedic Physiotherapy Practitioner, Doncaster, UK To by Hall MSc PhD PGDip (Manip Ther) FACP Adjunct Senior Teaching Fellow, Curtin Innovation Health Research Institute, Curtin University of Technology; Senior Teaching Fellow, The University of Western Australia, Perth, WA, Australia Elly He ng e ve ld MSc BPT OMTs vomp Clin Spec f s ios wis s / MSK IMTA Member
Senior Teacher IMTA, Oberentfelden, Switzerland
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Kim Ro bins o n BAS (Phys io), PG Dip (Man Ther) FACP Fellow of the Australian College of Physiotherapists (FACP); Member of the Mulligan Concept Teachers’ Association; Adjunct Senior Teaching Fellow, Curtin University; Senior Teaching Fellow, The University of Western Australia, Perth, WA, Australia
Biography Ge o ffre y Do ug las Maitland MBE AUA FCSP FACP (Mo no g raph), FACP (Spe c ialis t Manipulative Phys io the rapis t) MAppSc (Phys io the rapy) G eoff Maitland worked initially at the Royal Adelaide H ospital and the Adelaide Children’s H ospital, with a main interest in the treatment of orthopaedic and neurological disorders. Later he became a part-time private practitioner and part-time clinical tutor at the School of Physiotherapy at the University of South Australia. H e continuously studied and spent half a day each week in the Barr–Smith Library and the excellent library at the Medical School of the University of Adelaide. H e immediately showed an interest in careful clinical examination and assessment of patients with neuromusculoskeletal disorders. In those days assessment and treatment by speci c passive movements were under-represented in physiotherapy practice. G D Maitland learned techniques from osteopathic, chiropractic and bonesetter books as well as from medical books such as those of Marlin, Jostes, James B Mennell, John McMillan Mennell, Alan Stoddard, Robert Maigne, Edgar Cyriax, James Cyriax and many others. H e maintained an extensive correspondence with numerous authors worldwide, who published work on passive mobilizations, manipulation and related topics as for example MacNab from Canada and Alf Breig from Sweden. As a lecturer, he emphasized clinical examination and assessment. H e stimulated students to write treatment records from the very beginning, as he felt that ‘one needed to commit oneself to paper to analyse what one is doing’. In 1954 he started with manipulative therapy teaching sessions. In 1961 he received an award from a special studies fund, which enabled him and his wife Anne to go overseas for a study tour. They visited osteopaths, chiropractors, medical doctors and physiotherapy colleagues whom they had heard and read about and corresponded with in the preceding years. In London, G eoff had interesting lunchtime clinical sessions and discussions with James Cyriax and his
G.D. Maitland (1924–2010), was born in Adelaide, Australia, trained as a physiotherapist from 1946 to 1949 after serving in the RAAF during the Second World War in Great Britain.
staff. From this tour G D Maitland established a friendship with G regory P G rieve from the UK. They had extensive correspondence about their clinical experiences and this continued for many years. Maitland delivered a paper, in 1962, to the Physiotherapy Society of Australia entitled ‘The Problems of Teaching Vertebral Manipulation’, in which he presented a clear differentiation between manipulation and mobilization and became a strong advocate of the use of gentle passive movement in the treatment of pain, in addition to the more traditional forceful techniques used to increase range of motion. In this context it may be suitable to quote James Cyriax, a founder of orthopaedic medicine and of major in uence on the development of manipulative therapy provided by physiotherapists: … more recently Maitland, a physiotherapist from Australia, has been employing repetitive thrusts of lesser frequency but with more strength behind them. They are not identical with the mobilizing techniques that osteopaths misname ‘articulation’, nor are they as jerky as chiropractors’ pressures. The great virtue of vii
Bio g raphy Maitland’s work is its moderation. H e has not expanded his manipulative techniques into a cult; he claims neither autonomic effects nor that they are a panacea. Indeed, he goes out of his way to avoid theoretical arguments and insists on the practical effect of manipulation … The patient is examined at frequent intervals during the session, to enable the manipulator to assess the result of his treatment so far. H e continues or alters his technique in accordance with the change, or absence of change, detected. These mobilizations clearly provide the physiotherapist with a useful addition to those of orthopaedic medicine and, better still, with an introduction to them. She gains con dence from using gentle manoeuvres and, if the case responds well … need seek no further. Cyriax J 1984 Textbook of Orthopaedic Medicine. Part II – Treatment by Manipulation, Massage and Injection, 11th edition. Ballière-Tindall, London. pp 40–41.
G D Maitland became a substantial contributor to the Australian Journal of Physiotherapy as well as to other medical and physiotherapy journals worldwide. O n the instigation of Monica Martin-Jones, O BE, a leader of the Chartered Society of Physiotherapy in G reat Britain, Maitland was asked to publish his work, which resulted in the rst edition of Vertebral M anipulation in 1964, which was followed by a second edition in 1968. The rst edition of Peripheral M anipulation was published in 1970, in which the famous ‘movement diagram’ was introduced, an earlier co-production with Ms Jennifer H ickling in 1965. O ver all the years of lecturing and publishing, Maitland kept treating patients as the clinical work remained his main source of learning and adapting ideas. G eoff treated patients in his private practice for over 40 years and although he closed his practice in 1988, he remained active in treating patients until 1995. In 1965, one of Maitland’s wishes came true; with the help of Ms Elma Caseley, H ead of the Physiotherapy School, South Australian Institute of Technology and the South Australian Branch of the Australian Physiotherapy Association, the rst three months course on Manipulation of the spine was held in Adelaide. In 1974 this course developed into the one-year postgraduate education ‘postgraduate diploma in manipulative physiotherapy’ at the South Australian Institute of Technology, now a master’s degree course at the University of South Australia. H e was one of the co-founders, in 1974, of the International Federation of O rthopaedic Manipulative Physical Therapy (IFO MPT), a branch of the World Confederation of Physiotherapy (WCPT). viii
O nly in 1978, while teaching one of his rst courses in continental Europe in Bad Ragaz, Switzerland, did he recognize, through discussion with Dr Zinn, Director of the Medical Clinic and the Postgraduate Study Centre in Bad Ragaz, that in fact his work and ideas were a speci c concept of thought and action rather than a method of applying manipulative techniques. The Maitland Concept of Manipulative Physiotherapy as it became known emphasizes a speci c way of thinking, continuous evaluation and assessment and the art of manipulative physiotherapy (‘know when, how and which techniques to perform, and adapt these to the individual situation of the patient’) and a total commitment to the patient. Maitland has held a long and extensive commitment to various professional associations:
• Australian Physiotherapy Association (APA)
• • • •
where he was on the State branch committee for 28 years in various capacities and a State Delegate to Federal Council for 11 years. In conjunction with others, he was responsible for the revision of the constitution of APA in 1964–1965 In 1977, he put forward a submission regarding Specialization in Manipulative Physiotherapy, a concept which was subsequently accepted in modi ed form. Inaugural President of the Australian College of Physiotherapists for six years and a member of the council for a further six years. Member of the Physiotherapy Registration Board of South Australia for 22 years. Chairman of the Expert Panel for Physiotherapy for Australian Examining Council for O verseas Physiotherapists (AECO P) for 11 years. Australian delegate to IFO MPT for ve years and a member of its academic standards committee for another ve years.
For his work he was honoured with several awards:
• Member of the O rder of the British Empire in 1981. • Fellowship of the Australian College of Physiotherapists by Monograph in 1970, with a further Fellowship by specialization in 1984. • H onorary Degree of Master of Applied Science in Physiotherapy from the University of South Australia in 1986.
B io g ra p h y
• H onorary Fellow of the Chartered Society of Physiotherapy (G B). • H onorary life memberships of the South African Society of Physiotherapy, including the G roup of Manipulative Physiotherapy, Manipulative Physiotherapy Association of Australia (MPAA), Swiss Association of Manipulative Physiotherapy (svomp), G erman Association of Manual Therapy (DVMT), the American Physical Therapy Association (APTA) and the International Maitland Teachers’ Association (IMTA). • H e received an award from IFO MPT in appreciation of his service and leadership from its foundation. • Mildred Elson Award by the World Confederation of Physical Therapy (WCPT) for his life’s work in 1995. In 1992 in Zurzach, Switzerland, the International Maitland Teachers’ Association (IMTA) was founded, of which G D Maitland was a founding member and inaugural President. All this work would not have been possible without the loving support of his wife Anne, the mother of their two children John and Wendy. Anne did most of the graphic arts in Maitland’s publications, kept notes, made manuscripts and videotaped many of his courses. Their continuous feedback discipline has been one of the very strengths of the Maitlands, who have been practically inseparable since they met in England during the second World War. Anne was awarded the protectoress of the Dutch Association of O rthopaedic Manipulative Therapy (NVO MT). Maitland’s work, especially through the mode of thinking and the process of continuous assessment, has laid the foundation for the development of contemporary de nitions and descriptions of the physiotherapy process. H is life’s work has been acknowledged by numerous authors in obituaries at the time of his passing in 2010: … G eoff will be remembered by countless physiotherapists in Australia and overseas.We acknowledge the passing of a truly great clinician, teacher and mentor. P Trott, R Grant, 2010, Manual Therapy. 15:297
… G eoff Maitland’s contribution to the physiotherapy profession, and in particular to musculoskeletal physiotherapy cannot be underestimated. H is inspiration and collaboration with our own UK pioneers led to the
development of the MACP and really set the foundations for all the extended scope roles and postgraduate physiotherapy education that we enjoy today. MACP, 2010, Manual Therapy. 15:298–299
… G eoff was a great listener and a great communicator. H e placed a great emphasis on the art and skill of listening [as opposed to just hearing]. H e would hang on every word his patients would say so that he did not miss the subtle hints from the language or its tone that would help him understand, in depth, what the individual was experiencing. H e would use every facet of ‘the bodies capacity to inform’ both verbal and nonverbal. H e would spot the almost imperceptible nuances of the patient’s responses to his treatment. O nly he would recognise, in a room full of students, the important meaning of a patient drumming his ngers on the couch. G eoff was a visionary and an innovator. In the preface to the rst edition of Vertebral Manipulation [1964] he recognises ‘The practical approach to the use of manipulation is to relate treatment to the patient’s symptoms and signs rather than to diagnosis’ and that ‘it is often impossible to know what the true pathology is … symptoms and signs [of a disc lesion] may vary widely and require different treatments’ H is vision was instrumental in giving us what are now established competencies, including, ‘PatientCentred Care’, the use of mobilisation for pain modulation, and an awareness of ‘the nature of the person’ and ist impact on treatment. H e highlighted the need for deep and broad theoretical knowledge to support and inform clinical practice. H e advocated the discipline of evaluating everything we do to prove our worth and with this came the use of patient reported and orientated outcome measures [subjective and functional asterisks] and the demand for accurate recording of treatment and its effects. G eoff was also at the forefront of research by Physiotherapists for Physiotherapist at a time when it was seen as the role of the Doctor to report on Physiotherapy and decide which Physiotherapy modalities should be prescribed. In summary, G D Maitland supported by Anne and his close family and colleagues has established his place in our Profession’s H istory. H e is the Donald Bradman of Physiotherapists. Sir Donald, a fellow Australian, had a career Test Match batting average of 99.94 and, as with G eoff, many have aspired to reach such a standard but none, to date, have come anywhere near. Chairman and members of the International Maitland Teachers’ Association, IMTA, 2010, Manual Therapy. 15:300–301
Within this context it seems suitable to conclude with a quote from Professor Lance Twomey, Vice ix
Bio g raphy
Chancellor, Professor of Physiotherapy, Curtin University of Technology, Perth, Australia: … Maitland’s emphasis on very careful and comprehensive examination leading to the precise application of treatment by movement and followed in turn by the assessment of the effects of that movement on the patient, form the basis for the modern clinical
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approach. This is probably as close to the scienti c method as is possible within the clinical practice of physical therapy and serves as a model for other special areas of the profession. Foreword in Refshauge K & Gass E, 1995, Musculoskeletal Physiotherapy. Butterworth-Heinemann, Oxford. p IX
Kevin Banks, Elly H engeveld
Preface The vision or this new edition o M aitland’s Peripheral M anipulation was to bring together a group o experts in their f eld who have a deep and broad working knowledge o the Maitland Concept o manipulative/ musculoskeletal (MSK) physiotherapy, which underpins their clinical practice. The basic principles o this concept o MSKphysiotherapy are as valid today as they were when this special approach to clinical practice was f rst developed. An obituary written a ter the death o G eo Maitland in January 2010 expresses the legacy, which the editors and authors o this book wish to carry on: … I particularly re ected on my f rst meeting with him in Melbourne and my f rst experience o hearing him as a speaker at IFO MT 1988 in Cambridge in the UK. At the congress, in ront o 200 people, G eo examined an unseen patient, a male patient, who I believe was a traveller. H e was a very shy man who had had spinal problems or some time and was clearly experiencing much physical discom ort. Being in ront o an audience o 200 people was probably equally discom orting and this gentleman’s physical problem clearly needed some time on behal o the therapist to unravel the real problems and to undertake a thorough clinical reasoning process. In this situation many presenters might tend to ocus on the audience’s needs rather than those o the patient simply because o time constraints and the objective o living up to the expectations o the audience. G eo , however, was di erent. There was no question as to who the most important person was in the auditorium – it was the patient. G eo sat with his back to the audience, close to the patient, whom he shielded rom the audience. We could, however, all hear the conversation that was in ow and the care ul and meaning ul dialogue that ensued and we could see later the very gentle but purpose ul examination that took place. The audience was transf xed, enraptured and silent. The man who advocated listening in his early textbooks really did listen and he was an exemplar in terms o patientcentred care and an example to us all. I already had a great respect or G eo rey Maitland and knowledge o his approach changed my practice hugely, as I am sure it has or thousands o physiotherapists worldwide. G eo ’s per ormance at the IFO MT con erence was exemplary and yet so understated. It is an event that I shall remember orever and one that I think signif cantly in uenced my clinical practice, my
teaching and even my approach to research. When I met G eo rey Maitland in Melbourne some years later he was once more very person-centred, sel -e acing, humble, genuine and elt truly like someone you could trust. H is position during that conversation was clear. H e praised eclectic approaches to musculoskeletal therapy and he was very welcoming o new and uture developments in the discipline. A P Moore, 2010. With sadness on the passing of Geoffrey Maitland 22.01.2010. Manual Therapy 15:211
G eo Maitland always stressed that there were no such things as ‘Maitland Techniques’, just techniques o passive mobilization specif cally designed around the individual patient’s physical problems. The chapters in this edition, there ore, are not technique driven as such. Instead, each chapter re ects an expertise and the diverse clinical domains within which the Maitland Concept operates e ectively. Each chapter stands alone as a ‘master class’. Chapter 1 ‘The Maitland Concept as a clinical practice ramework or neuromusculoskeletal disorders’ by Kevin Banks and Elly H engeveld places the Maitland Concept within an evidence-based practice domain. Chapter 2 ‘The Maitland Concept: evidencebased practice and the movement sciences’ by Elly H engeveld details how a paradigm shi t in the ocus o healthcare by pro essions such as physiotherapy is gathering momentum. Chapter 3 ‘Management o craniomandibular disorders’ by John Langendoen re ects the emerging role that physiotherapists have in helping patients with a range o craniomandibular dys unctions and impairments. Chapter 4 ‘Management o shoulder and shoulder girdle disorders’ by Matthew Newton and Phil Ackerman shows how the principles o the Maitland Concept are underpinning extended scope practice. Chapter 5 ‘Management o elbow disorders’ by Toby H all and Kim Robinson reveals how physiotherapists are using knowledge and evidence rom the literature to shape their clinical reasoning and recognizes that the integration o skills in manual therapy, motor control and neurodynamics is essential in practice. xi
Pre fac e
Chapter 6 ‘Management o wrist and hand disorders’ by Pierre Jeangros highlights that there is a need or more than just manual therapy skills in practice and that the bio-psychosocial impact o impaired hand unction needs as much recognition. Chapter 7 ‘Management o hip disorders’ by Dianne Addison emphasizes the role o manual therapy within the context o the f ne tuning o movement. Chapter 8 ‘Management o knee disorders’ by G erti Bucher-Dollenz and Elly H engeveld ocuses the clinician’s attention away rom biomedical diagnosis and more towards the exploration and therapeutic recovery o unctional capacity and perormance o movement disorders o the knee complex. The f nal chapter ‘Management o oot and ankle disorders’ by Jukka Kangas shows the link between clinical reasoning and the development o a clear practice ramework or classif cation and there ore therapeutic management o restriction and control impairments o the oot. In all cases the principles and practice o the Maitland Concept clearly underpin the integrated and diverse range o available interventions used in practice. While mobilization techniques are still central to the management o many movement-related
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neuromusculoskeletal disorders, in other cases they support and enhance other strategies such as recovery o motor control, restoration o healthy neurodynamics, physical reconditioning and support to patients in understanding their pain and its mechanisms. Anti-nociception and unctional gain are the clear outcomes o mobilization and manipulation techniques supported by or supporting a range o physical therapy interventions. From an individual perspective, however, these outcomes can only be achieved through collaboration with the patient (the patient at the centre), a clinical-reasoning model or decision making (the symbolic permeable brick wall), thorough and detailed assessment (examination and analytical assessment) and a means o evaluating responsiveness to therapies (reassessment). As co-editors we hope you enjoy dipping into this text and accessing the companion website (www. maitlandsresources.com) to support the construction o your own knowledge and understanding o manipulative physiotherapy and the Maitland Concept. We hope this will give you plenty o deep and contextual learning opportunities to develop your own practice and personal learning goals. Kevin Banks, Elly H engeveld 2012
Acknowledgements Kevin would like to thank Elly for helping to bring this vision to its conclusion. Both Kevin and Elly are grateful to Sheila Black and Rita Demetriou-Swanwick from Elsevier for their support, advice and patience. Kevin would also like to thank Robbie Blake and Peter Wells for their unwavering support and for being the best role models anyone could ever hope for. A big thank you goes to colleagues at Doncaster and Bassetlaw NH S Foundation Trust for their critical appraisal of some of the material. To Stefan Karanec, thank you for the contribution. Thanks also to all the authors of the individual chapters for entering into the spirit of things and sharing their expertise with all of us. Last but not least, my gratitude goes to Nancy, my ercest critic, for being there and for her friendship. I am forever in your debt.
Elly is grateful to Kevin for his thorough preparation of this book, his patience and ongoing support throughout the whole process of writing. Thanks also to all the contributors of this book, who carefully expressed their insights related to this concept of practice. A warm thank you goes to all students and colleagues: their queries during teaching and clinical practice have helped in the seeking of answers to many clinical and theoretical questions. Elly also expresses her gratitude to Matthew Newton for his invaluable help at the completion of the electronic version of this publication. Charles, my greatest friend in life: there are no words for all the things I have been able to learn and to give by living and unfolding in life with you.
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In Memoriam: Kevin Banks (1959–2012) It is with great sadness that we learned of the death of Kevin Banks. Kevin passed away on 14 November 2012 aged 53 after a short illness. Kevin has been involved as a co-editor with Elsevier’s M aitland’s Peripheral M anipulation, M aitland’s Vertebral M anipulation and M aitland’s C linical Companion. H e passed away as we were completing the manuscripts for the new editions of M aitland’s Peripheral M anipulation and M aitland’s Vertebral M anipulation, which he will sadly not be able to see in their nal versions. Kevin was a senior teacher and founding member of the International Maitland Teachers’ Association (IMTA). H is enquiring thoroughness and critical input played a decisive role in IMTA’s further development as an educational institute. We have lost a friend and colleague dedicated to the teaching and further development of the principles of manipulative or neuromusculoskeletal physiotherapy as initiated by G D Maitland. Kevin saw himself as a practising Clinician and Clinical Educator. H is belief that a structured yet exible clinical practice framework, along with a detailed grounding
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in clinical reasoning, communication and wise action decision making, is essential for best practice was at the heart of his teaching. Kevin really was a visionary. H e knew where his professional area of specialism needed to develop and how to get it there, in a way that many did not. H e stated of himself: ‘I am driven by the need to enhance learning in a broad and deep range of skills, knowledge and attributes within physiotherapy to ensure that patients have as good a deal as possible.’ The patient and their needs were indeed the centre of all he did and strived for in his professional life. We knew Kevin as a gentle and dedicated person. Many of us have enjoyed his often subtle and unexpected humour and most of all his friendship and kind-heartedness. Kevin has been suddenly taken from us in the prime of his life. We are proud to have been associated with him and will miss him. O ur sympathy and thoughts are with wife, Nancy and his children Richard, William and H elen. Elly H engeveld Sheila Black and Rita Demetriou-Swanwick (Elsevier)
Glossary Chapte r 1 The Maitland Co nc e pt as a c linic al prac tic e frame wo rk fo r ne uro mus c ulo s ke le tal dis o rde rs As s e s s me nt – includes all procedures which are undertaken to monitor the therapeutic process throughout all encounters between the physiotherapist and the patient. Assessment procedures do not stop a ter the f rst examination at initial consultation in which the physiotherapist comes to a diagnosis o the movement disorder o the patient and develops collaboratively with the patient a treatment plan; assessment is an ongoing analytical process throughout all therapy sessions. 1. Analytical assessment – examination and planning at a f rst consultation. 2. Assessment during every treatment session – determines the e f cacy and duration o a technique at a particular stage in treatment. 3. Final analytical assessment – re ects on the f nal outcome o treatment and prognosis o the disorder a ter completion o therapy. 4. Pretreatment assessment – considers the e ects o the previous treatment session. 5. Retrospective and progressive assessment – compares the e ects o treatment over three or our sessions; particularly, looks back and re-evaluates treatment when progress has stopped or slowed. (Maitland 1987). Auto no mo us prac tic e – re ers to a health pro essional who is able to work without medical re erral, appropriate to their education.
that the social world is always Bric k wall – the symbolic permeable linked with the inner experience brick wall is a unique mode o o eeling ill. In this experience thinking advocated in the powers may exist that can either Maitland Concept which involves ampli y or reduce su ering and the separation o thinking into a disability including the behaviours theoretical and clinical o other, as relatives or clinicians compartment, so that thoughts (Kleinmann 1988). This notion is related to the theory o the being supported by Pilowsky patient’s disorder may guide, but (1997), who argues that clinicians should not inhibit the discovery o need to be aware o the in uence the f ner details o the clinical o their behaviour on the in ormation. behaviour o the patients they are Clinic al re as o ning – ‘The thinking treating. Furthermore, there is underpinning clinical practice.’ indication that the clinical Clinical reasoning is a process in reasoning o physiotherapists may which the therapist, interacting be di erent, dependent on the with the patient and signif cant culture in which they are active others (e.g. amily and other (Cruz et al. 2012), hence being to health care team members) accentuate certain behaviours structures meaning, goals and within themselves and their health management strategies clients. based on clinical data, patient choices and pro essional Evide nc e -bas e d prac tic e – judgement, knowledge and skills conscientious, explicit and (H iggs & Jones 2000). judicious use o current best evidence in making decisions Evide nc e -bas e d prac tic e – the about the care o individual application o knowledge and skills patients. The practice o evidencethat in orm and support clinical based medicine means integrating practice and the use o research individual clinical expertise with and clinical evidence to ensure the the best available external clinical best available assessment and evidence rom systematic research treatment o the individual patient (Sackett et al. 1998). and populations o patients. Individual illne s s e xpe rie nc e – the personal experience o bodily Chapte r 2 The Maitland processes and the impact o social Co nc e pt: e vide nc e -bas e d and cultural in uences on this prac tic e and the mo ve me nt experience. s c ie nc e s See Bio-psychosocial perspective. Bio -ps yc ho s o c ial pe rs pe c tive – it Mo de ls o f prac tic e – various theoretical models, such as is suggested that various actors pathobiological models to may contribute to the bio-psychosocial paradigms, development and maintenance o physiotherapy-specif c, movementdisease, pain and disability. the oriented paradigms, illness experience is always neurophysiological theories, culturally shaped and is dependent client-centred perspectives, etc. on what a society regards as used to guide clinical decision appropriate behaviour, on the making. personal biography o the person, and on psychological processes, Saluto g e ne s is – a pathogenic meanings and relationships, so perspective mainly ocuses on xv
Glo s s ary
causative actors and the prevention o diseases and other disorders whereas a salutogenic perspective concentrates on the reasons why people stay healthy in spite o the presence o health-risk stressors, and which actors can guide them to f nd a better sense o health and well-being. As stated by Antonovsky (1979) ‘salutogenic actors are not necessarily the other side o the coin o pathogenic actors’. H e concluded that a ‘sense-o -coherence’ supports a better resilience to li e-stressors. This construct supports the development and maintenance o a sense o health, sense o purpose and well-being. H e postulated that health is not a f xed state, but patients move on a continuum between two extremes o ‘dis-ease and ease’. In the examination o patients those actors need to be evaluated which lead to a backward and orward movement on this health–disease continuum. Salutogenetic perspectives play a central role in health promotion programmes. Ne uro phys io lo g ic al pain me c hanis ms – an individual’s pain experience should be ascribed to diverse mechanisms o altered nervous system processes rather than to a single neurophysiological pain mechanism (Cervero & Laird 1991) and to elements o neuroplasticity or learning processes (Loeser & Melzack 1999). The suggested neurophysiological mechanisms encompass peripheral nociceptive processes, peripheral neurogenic mechanisms, central nervous system modulatory mechanisms and autonomic nervous system mechanisms. The clinician needs to relate active nociceptive and peripheral neurogenic mechanisms to possible tissue pathology (end-organ dys unction), which needs urther medical action or serves as a specif c precaution or contraindication to physiotherapeutic interventions. xvi
The clinician should also consider the ways in which the altered nervous system processing is in uencing the pain experience and disability o a person and how the physiotherapeutic treatment should be adapted to these mechanisms.
contacts made when the jaw is moving, as with chewing. Parafunc tio nal habit – involuntary use o voluntary muscles o a body part in a way that is other than the most common use o that body part. It mostly occurs in dentistry and re ers to involuntary, habitual use o the mouth, tongue and jaw. O ral para unctional habits may include bruxism (tooth Chapte r 3 Manag e me nt o f clenching or grinding), tongue c ranio mandibular dis o rde rs pressing, cheek sucking, lip tics, Bruxis m – subconsciously grinding or nail biting, even mouth breathing, clenching the teeth together, and any other regular use o the usually during sleep. Bruxism is mouth unrelated to biting, associated with stress states and chewing (eating), drinking, results in myo ascial pain and swallowing or speaking. associated pain rom the Re c ipro c al c lic king – a clicking temporomandibular joints. sound occurring during excursive Ce ntric re latio n – physiological and incursive mandibular position o the caput mandibulae movements that appears to arise in the resting position o the rom within the mandible as well as in maximum temporomandibular joint. intercuspation, which is def ned as Splints – devices placed on the maximum cephalad, maximum lower or upper teeth rows to anterior and midway lateralmanage a number o complaints medial position o the head o the such as abrasia o the teeth due mandible in the ossa. to bruxism, or to deload the Cranio mandibular c o mple x temporomandibular joint sur aces – describes not only the and articular disc or to restore temporomandibular joints but also centric relation. the unctional interrelationships Tris mus – sustained contraction o between the skull, the cervical the jaw muscles (‘lockjaw’). spine, the thorax, the mandible, the teeth, the tongue, the hyoid and the larynx. Chapte r 4 Manag e me nt o f Guidanc e , inc is al and c anine s ho ulde r and s ho ulde r – physiological contact between g irdle dis o rde rs incisives during protraction and canines during lateral movements Exte nde d s c o pe prac titio ne r o the mandible. (ESP) – def ned by the United Malo c c lus io n – misalignment o Kingdom’s Chartered Society o teeth and jaws, or more simply, a Physiotherapy (C SP) as ‘a clinical ‘bad bite’, such as an overbite, a physiotherapy specialist, in any loss o the vertical dimensions o recognized speciality, with an the lower mandible in relation to extended scope role, e.g. the skull dimensions. requesting X-rays, scans, blood Oc c lus io n – contact o the chewing tests, nerve conduction studies sur aces o the teeth. More etc.’ Traditionally tasks such as precise, it means the relationship these would have been undertaken between the maxillary (upper) by the medical pro ession, but and mandibular (lower) teeth with additional training and when they approach each other, as development they may be occurs during chewing or at rest. per ormed by physiotherapists with an extended role. Static o c c lus io n – contact between teeth when the jaw is closed and Diag no s tic utility – the value and stationary, while dynamic ability o a specif c test to be occlusion re ers to occlusal diagnostically discrimatory.
G lo s s a ry
Impairme nt-bas e d tre atme nt – identif cation o impairments, which contribute to a patient’s unctional limitations and possible disabilities with the aim o maximizing movement potential and quality o li e. This is in contrast to the biomedical model and way o thinking, which is concerned with identi ying pathology and diagnostic labels to speci y a disease on which decisions are made regarding examination and treatment. Me dic al diag no s is – ‘The determination o the cause o a patient’s illness or su ering by the combined use o physical examination, patient interview, laboratory tests, review o the patient’s medical records, knowledge o the cause o observed signs and symptoms, and di erential elimination o similar possible causes‘(Mosby’s Medical Dictionary 2009). Ortho pae dic s pe c ial te s ts – medical physical examination tests which aim to test or the presence o a specif c pathology or medical diagnosis. Phys io the rapy diag no s is – concerned with classi ying the consequences o a patient’s disease, injury or disorder – the impairments, unctional limitations and disabilities as well as with the diagnosis o movement disorders which may precede pathobiological processes (WCPT 2007, Zimny 2004, Jette 1989, G uccione 1991). Sc re e ning – triaging process whereby patients with specif c conditions are managed according to their need or care.
Chapte r 5 Manag e me nt o f e lbo w dis o rde rs Late ral e pic o ndylalg ia – syndrome whereby pain is experienced over or around the lateral epicondyle o the elbow. Such a disorder is characterized by di f culty or loss o unctional activities involving gripping because o lateral epicondylar pain.
anatomical snu o the wrist. Mo bilizatio n with mo ve me nt Treated conservatively, unless – treatment technique combining there is severe pain and signif cant an accessory joint glide with an loss o unction. active movement or activity. Guyo n’s c anal s yndro me – Uppe r limb ne uro dynamic te s ts entrapment o the ulnar nerve – examination procedures used to within the G uyon canal tunnel at evaluate the mechanical sensitivity the wrist. Symptoms are o the neural structures in the experienced in the cutaneous upper limb, in particular the distribution o the ulnar nerve. radial, ulnar and median nerves. Dupuytre n’s c o ntrac ture – predominantly inherited disorder Chapte r 6 Manag e me nt o f o the ascia o the palm o the wris t and hand dis o rde rs hand characterized by progressive exion contracture o the little No npre he ns ile func tio n – use o and ring f ngers. the hand or activities other than gripping, such as pushing, pulling, Te ndino pathy – overuse or overstretching injury, involving weight bearing and non-verbal mostly the extensor tendons communication. around the wrist (Ashe et al. Re habilitatio n – restoration o 2004). A paradigm shi t should unction through therapeutic be considered: the process is intervention and training. more degenerative than Se ns o ry and mo to r in ammatory. re pre s e ntatio n – in the sensory Warte nbe rg ’s dis e as e o r and motor cortex, the hand, and c he iralg ia pare s the tic a especially the thumb, has a much – sensitive neuropathy involving greater representation than many the superf cal branch o the radial other body areas. nerve. Wris t ins tability o r lig ame nt Clas s i c atio n o f ne uro s prains – tendency or static or mus c ulo -s ke le tal dis o rde rs dynamic subluxation or malposition o the carpal bones. Arthritis – joint and bone disease. Vo lkmann’s is c hae mic Carpal tunne l s yndro me – c o ntrac ture – ischaemic entrapment o the median nerve retraction o the muscles o the within the carpal tunnel at the anterior compartment o the wrist. Symptoms are experienced orearm, resulting in pronation o in the cutaneous distribution o the orearm, exion o the wrist the median nerve. Night pain is a and hooked f nger exion key eature. (extension o the proximal CRPS (Co mple x Re g io nal Pain phalanx, exion o the middle and Syndro me o r Sude c k’s distal phalanx). atro phy) – re ex sympathetic dystrophy o the extremities (the hand and oot), o ten a Chapte r 7 Manag e me nt o f consequence o injury to the hip dis o rde rs hand. The disorder is characterized by severe pain Fle xio n/adduc tio n – unctional (Allodynia and hyperalgesia), movement o the hip, which can swelling, trophic changes and be used to detect and treat progressive sti ening o the minor or less obvious pain ul joints. restrictions. de Que rvain’s dis e as e – Intra-artic ular dis o rde r – tenosynovitis o the tendon sheath movement disorder and symptoms o the abductor pollicis longus and coming rom intra-articular extensor pollicis brevis. structures. It requently requires compression in examination or Gang lio n – cyst o the wrist, treatment procedures. tenosynovial in origin, within the xvii
Glo s s ary
Movements o the patello emoral Mo to r c o ntro l – or adequate joints are requently involved. motor control the appropriate Treatment o ten consists o muscle f bre type should be passive mobilization and recruited. All human muscles normalization o the patella contain tonic and phasic muscle tracking through the emoral f bres. For low-level activity groove by activation o the vastus (activities requiring approximately medialis oblique (VMO ) in 25% o a maximal voluntary relation to the vastus lateralis and contraction) selective recruitment the overall muscle chain o the o only the tonic f bres is pelvis and oot (McConnell necessary or stability. For 1996). Contributing actors such high-level activity maximal tonic as oot, hip, pelvic and trunk recruitment together with phasic alignment, mobility and stability f bre recruitment is essential. dys unctions in this area have to Multic o mpo ne nt mo ve me nt be addressed as well. dis o rde rs – although some Exte ns io n/abduc tio n, e xte ns io n/ patients may be re erred with adduc tio n, e xio n/abduc tio n, a biomedical diagnosis which e xio n/adduc tio n – unctional indicates a disorder in a certain movements o the joint area (e.g. osteoarthritis), (‘ unctional corners’) which can requently more movement be used in the examination and components contribute to the treatment o minor or less obvious disorder. Many problems in the hip pain ul restrictions. area show movement dys unctions o the hip joint in combination Jo int s tability – provided by the with the lumbar spine, sacroiliac ligamentous structures (passive joints, neurodynamic structures stability) and the surrounding and the muscular system. muscles (dynamic stability). Stabilizatio n training – allows supporting tissues such as Chapte r 8 Manag e me nt o f ligaments to heal, to strengthen kne e dis o rde rs surrounding musculature, and to re-establish motor control and Ante rio r kne e pain/pate llo fe mo ral appropriate movement patterns o pain s yndro me – condition with the knee, including joint position symptoms in the area o the sense. anterior aspect o the knee.
Chapte r 9 Manag e me nt o f fo o t and ankle dis o rde rs Dis o rde r – all cumulative eatures and anomalies resulting rom presumed initial tissue pathology. Disorder re ers to both pathology and e ects. Pathology and e ects may be physical or psychological (Elvey & O ’Sullivan 2004). Manag e me nt – specif c or general intervention per ormed by the patient under the direction o or prescribed by the clinician (Elvey & O ’Sullivan 2004). Mo to r c o ntro l impairme nts o f the fo o t and ankle – lack o motor control drives the pain disorder and results in monotonic loading patterns and pain in the oot and ankle. Motor control impairments o the oot and ankle present in a directional manner (Kangas et al. 2011). Mo ve me nt impairme nts o f the fo o t and ankle – loss o normal physiological movement drives the pain disorder. Movement is lost in the direction o pain provocation. Movement impairments o the oot and ankle present in a directional manner (Kangas et al. 2011). Tre atme nt – specif c intervention per ormed by the clinician (Elvey & O ’Sullivan 2004).
References Antonovsky A: H ealth, Stress, and Coping: N ew Perspectives on M ental and Physical Well-Being, San Francisco, 1979, Jossey-Bass. Ashe M, McCauley T, Kahn K: 2004 Tendonopathies in the upper extremity: a paradigm shi t, Journal of H and Therapy 17(3):329–334, 2004. Cervero F, Laird JMA: O ne pain or many pains? A new look at pain mechanisms, N eural Information Processing Systems (N IPS) 6: 268–273, 1991. Cruz EB, Moore A, Cross V: Clinical reasoning and patient-centred care in musculoskeletal physiotherapy in Portugal: a qualitative study, M anual Therapy 17:246–250, 2012. xviii
Elvey RL, O ’Sullivan PB: 2004 A contemporary approach to manual therapy. In Boyling JD, Jull GA, editors: G rieve’s M odern M anual Therapy: The Vertebral C olumn, Edinburgh, 2004, Elsevier Churchill Livingstone, pp 471–493. G uccione AA: Physical therapy diagnosis and the relationship between impairments and unction, Physical Therapy 71(7):499–504, 1991. H iggs J, Jones M: Clinical Reasoning for H ealth Professionals. O x ord, 2000, Butterworth-H einemann. Jette AM: Diagnosis and classif cation by physical therapists: a special communication, Physical Therapy 69:967–969, 1989.
Kangas J, Dankaerts W, Staes F: New approach to the diagnosis and classif cation o chronic oot and ankle disorders: identi ying motor control and movement impairments, M anual Therapy 16:522–530, 2011. Kleinmann A: The Illness N arratives: Suffering, H ealing and the H uman C ondition, New York, 1988, Basic Books. Loeser JD, Melzack R: Pain: an overview, The Lancet 353:1607–1609, 1999. Maitland G D: The Maitland Concept: assessment, examination and treatment by passive movement. In Twomey L, Taylor J, editors: Physical Therapy o the Low Back. New York, 1987, Churchill Livingstone. vol 13, pp 135–155.
G lo s s a ry McConnell J: Management o patello emoral problems, M anual Therapy 1:60–66, 1996. Mosby’s Medical Dictionary, ed 8, 2009, Mosby. Pilowsky I: Abnormal Illness Behaviour, Chichester, 1997, John Wiley. Sackett D, Richardson SW, Rosenberg W, et al: Evidence-based medicine:
how to practice and teach EBM , Edinburgh, 1998, Churchill Livingstone. WCPT (World Con ederation or Physical Therapy): Position statement. Description o physical therapy. http:/ / www.wcpt.org/ sites/ wcpt.org/ f les/ f les/ WCPT_ Description_o _Physical_Therapy-
Sep07-Rev_2.pd (accessed 31 March 2013), 2007. Zimny N: Diagnostic classif cation and orthopaedic physical therapy practice: what can we learn rom medicine? Journal of O rthopaedic and Sports Physical Therapy 34: 105–115, 2004.
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This pa ge inte ntiona lly le ft bla nk
The Maitland Conc e pt as a c linic al prac tic e rame work o r ne uro mus c ulo s ke le tal dis o rde rs
1
Kevin Banks Elly H engeveld
C H AP TE R C O N TE N TS
There is hope in honest error;
Se tting the s c e ne – the Ma itla nd Conc e p t a s a c linic a l p ra c tic e ra me work
None in the icy perfections of the mere stylist.
1
The f ve p illa rs o c linic a l p ra c tic e
3
P a tie nt-c e ntre d p ra c tic e
4
Clinic a l re a s oning
9
(Mackintosh (1868–1928))
The equivalent within the Maitland Concept (Maitland 1991) is that manipulative physiotherapists should be driven to:
Exa mina tion
13
Inte rve ntions
28
Ad a p t, a d op t a nd imp rove
As s e s s me nt
30
Comp e te nc ie s ra me work a nd a utonomous p ra c tic e
46
The b io-p s yc hos oc ia l mod e l o he a lth c a re
50
Re s e a rc h a nd the Ma itla nd Conc e p t
54
The message here is that the Maitland Concept embraces change and advancement. Using critical appraisal, re ection upon practice and continual evaluation of the effectiveness of interventions, the manipulative physiotherapist is encouraged to look for new and innovating ways of helping patients. The authors of each of the brand new chapters of this edition of Peripheral Manipulation: Management of Neuromusculoskeletal Disorders take the reader through a journey of ‘adapting, adopting and improving’. In all cases the key features of the Maitland Concept underpin clinical reasoning and competency within a comprehensive, integrated and evolving clinical practice framework. The editors of this edition hope that in years to come the established principles and practice of the Maitland Concept will lead to many more changes to the future editions of this text. This chapter, therefore, details the clinical practice framework, which is grounded within the principles and practice of the Maitland Concept, and includes:
Key words Framework, pillars , competencies , bio–ps ychos ocial, res earch
Se tting the s c e ne – the Maitland Co nc e pt as a c linic al prac tic e rame wo rk A quotation by the Scottish architect and designer Charles Rennie Mackintosh (1868–1928) sums up the culture within which the Maitland Concept of manipulative and movement therapies operates:
1
C H AP TE R 1
The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
The f ve pillars o clinical practice P a tie nt-c e ntre d p ra c tic e Patient-centred practice demands a personal commitment to understanding, entirely, the patient experiences throughout an episode of health care. Placing the patient at the centre of everything we do means giving patients choices about their health care, including them in all aspects of decision making, collaborating with them at all times and giving them responsibility for compliance in and ownership of their own health care strategies.
Clinic a l re a s oning Clinical reasoning refers to the decision-making process by which the clinician can safely and effectively TH IN K, PLAN , EXECUTE to PRO VE. Effective clinical reasoning requires the clinician to consider all aspects of theoretical knowledge and research that may be relevant to the individual patient and all aspects of clinical evidence from examination and effects of treatment (Jones et al. 2006a, 2006b). By reasoning in action the clinician can apply knowledge and skills appropriately, leading to a desired outcome of intervention and by reasoning on action there can be a re ection and analysis of what has taken place in order that further or future management can be more effective.
Exa mina tion The examination, should be structured in two parts. Subjective examination (or C/ O – ‘complains of ’) ensures the gathering of clinical information about the patient’s experiences of their problem and the clinician’s manual examination (physical examination or P/ E) identi es and con rms the presence of physical impairments. The two examinations provide the detail the clinician needs to be able to plan and carry out appropriate interventions and management strategies.
Inte rve ntions Interventions of manipulative and movement therapies should be directly linked to the patient’s problems and identi ed physical impairments. A broad and deep range of reliable and effective interventions should be available and considered. 2
As s e s s me nt Assessment is the keystone holding decision making and progression of treatment together and ultimately leads to a collaborative outcome. Assessment is the analysis of clinical data and the timely evaluation of the effects of treatment or management strategies. Assessing and analyzing changes in a patient’s functional performance (C/ O parameters or ‘asterisks’) and movement capacity (P/ E parameters or ‘asterisks’) immediately before during and after each treatment, at regular intervals throughout the episode of care, and retrospectively when progress has slowed or stopped, supports the clinician’s decision making and ultimately the pathway to a shared and successful outcome.
Pro es s ional and clinical competencies s upporting phys iotherapis ts as autonomous practitioners International standards of manual therapy practice are determined by the International Federation of O rthopaedic Manipulative Physical Therapists (IFO MPT) through the federation’s educational standards committee (Beeton et al. 2008). The committee has identi ed 10 dimensions each with associated competencies of knowledge, skills and attributes. These competencies serve to ensure effective and expert practice in the speciality of manipulative and movement therapy. The assurance of quality standards also enhances the recognition of physiotherapy as a profession that can sustain itself autonomously within a de ned scope of practice and through collaborative work with other health professions and governmental organizations.
The bio-ps ychos ocial paradigm It is recognized that health professions such as physiotherapy operate most effectively within a biopsychosocial paradigm rather than the traditional biomedical model of health care delivery (Bazin & Robinson 2002). This paradigm shift within the profession has taken place over the last 10–20 years and has opened up many avenues for professional development. Diagnosis and a pathological basis for patients’ signs and symptoms are still very important, yet understanding the impact and health
Th e
consequences of illness, disease or injury can have a profound effect on an individual’s capacity to live a healthy life. The International Classi cation of Functioning, Disability and H ealth (ICF) (WH O 2001) is an ideal model on which to base an understanding of patients and their problems. The patients’ experiences can be evaluated from both a biological perspective and in the context of potential psychological and social factors. Physiotherapists can identify and make a difference to physical impairments that have their base in dysfunction (e.g. muscle weakness, joint stiffness, nerve sensitivity). Physiotherapists can identify and deal with performance and capacity issues in relation to activity limitations in life tasks and participation restrictions in life areas such as work, sport and recreation. The ICF domains also give the clinician the opportunity to identify personal and environmental mediators, which may contribute (positively or negatively) to recovery of health and assist in the broader assessment of prognosis. The physiotherapy domain therefore is changing with the paradigm shift to one where the focus is at the health care/ healthy living interface and where the physiotherapy profession has a greater role to play in public health and healthy life expectancy by advocating movement and exercise as a means to ensuring the adding of life to years (Middleton 2008).
Evid e nc e -in orme d p ra c tic e , re s e a rc h a nd the Ma itla nd Conc e p t Any clinical practice framework is embraced by a demand from service users and health care peers to provide evidence for interventions and competencies. Research and increasing knowledge help to inform practice. Both qualitative and quantitative research paradigms are important to the construction of knowledge and professional advancement. All clinical practice should be underpinned by sound knowledge, theory and research and likewise all research should have a practical clinical application and support clinical practice.
The Maitland Concept as a clinical practice ramework Figure 1.1 demonstrates the design characteristics of the Maitland Concept as a clinical practice framework.
ve p illa rs o f c lin ic a l p ra c tic e
Biopsychosocial model Health care/healthy living
Competencies Knowledge
Skills
Attributes
Assessment Examination
Patient centred
Clinical reasoning
Interventions
Evidence informed practice
Fig ure 1.1 • A clinical practice framework.
The detail of each component of the framework will now be analyzed within the context of manipulative physiotherapy practice. This will then form the basis for understanding the design and presentation of each individual chapter within this edition. For example, the chapter on shoulder conditions highlights how this framework has enhanced the professional development beyond the traditional scope of physiotherapy practice. The chapter on elbow conditions shows the use of the framework to enhance a multidimensional approach to practice. The chapter on hip conditions highlights how the principles apply to any identi ed impairment and are not exclusive to arthrogenic disorders.
The f ve pillars o c linic al prac tic e The following section will expand on the key features of the Maitland Concept as a clinical practice framework. Thinking in terms of ve key pillars of support will help the clinician to form a structural base for the application of clinical competencies in manipulative and movement therapies. The design of the framework will also help the clinician to understand its place in applying a bio-psychosocial model of health care and its place within an evidencebased practice environment. 3
C H AP TE R 1
The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
Patie nt-c e ntre d prac tic e Within each chapter of this edition you will be able to read how contributing authors maximize patientcentred practice to inform and enhance clinical decision making. A clear picture will emerge of the importance of engaging with the patient through attention to detail in questioning, clinical examination and manipulative physiotherapy treatment and reassessments. The importance of collaboration with patients will help physiotherapists to understand how inclusive decisions about assessment and treatment make for more effective outcomes. The key features to consider for effective patient-centred practice are:
• The patient and healthy living • Analyzing the patient’s individual illness • • • •
experience Patient inclusion and participation in decision making Patient-centred communication Understanding the body’s capacity to inform and adapt The role of collaborative reasoning.
The patient and healthy living The key requirement, therefore, of patient-centred practice is to address individual’s physical and mental well-being in order that they can function effectively, without de cit, in their daily life tasks and life areas (WH O 2001) (Table 1.1). Table 1.1 Activity limitations and participation restriction
Activity limitations–life tasks
Participation restrictions–life areas
Di f culties an individual may have in executing activities (tasks). For example: • bending orwards • walking • getting in and out o bed • li ting a box • reaching up to a shel • manual work • hitting a gol ball.
Problems an individual may experience in involvement in li e situations (areas) For example: • lack o disability- riendly transport • poor access to shops or a theatre.
WHO 2001
4
Box 1.1 Healthy life expectancy ‘Live Long Die Fa s te r’ The increas e o dis ability- ree li e expectancy Added years o relatively good health Dis ability is the los s o autonomy which older people ear and which in turn leads to dependency and its cos t implications Dis ability- ree li e expectancy s hould be a better meas ure o the well-being o an ageing population House of Lords 2005
The ultimate outcome of interventions of manipulative physiotherapy should be to ‘add life to years’ (Middleton 2008). The role of physiotherapy in maximizing movement potential is the key to promoting healthy living, functional capacity and physical tness (Chartered Society of Physiotherapy 2008) (Box 1.1).
Analyzing the patient experience The demand of the Maitland Concept is that patient care is driven by the patient’s own evaluation of their main problems, their expectations of therapeutic interventions and their personal goals. The therapeutic process, therefore, should begin with question 1 and question 2. The physiotherapist should always start by asking the patient question 1: ‘As far as you are concerned what is your main problem?’ For example, I have a painful and stiff shoulder. Secondly the patient should be asked question 2: ‘For you, what would be a successful outcome of physiotherapy treatment?’ For example, I want to be able to play badminton again without any pain or stiffness in my shoulder. This approach gives the physiotherapist evidence to support a range of decision-making hypotheses based on the answers given, including: • The patient’s perceptions and experiences (bio-psychosocial hypothesis). For example, I am worried that I may not be able to do my job properly. • The kind of disorder (pathobiological hypothesis) (Jones et al. 2006a). For example,
P a tie n t- c e n tre d p ra c tic e
•
•
•
•
•
•
Adhesive capsulitis causing painful and stiff shoulder movements. The patient’s symptoms (impairment hypothesis). For example, It is too painful for me to put my hand behind my back and too stiff to get things down off shelves at work. The impact of the disorder on the patients’ life areas and life tasks (activity limitations, participation restrictions). For example, I struggle to get dressed in the morning. I cannot sleep on my right side. I have had to stop playing badminton. Contributing factors (the cause of the cause). For example, I don’t think my shoulder problem is helped by the stiffness in my neck and spine since a car crash eight years ago. Ideas about management and treatment interventions. For example, pain modulation of shoulder joint pain, mobilization of a stiff joint and prevention of adaptive shortening due to protective/ adaptive posture and movement. Address contributing factors in the neck and spine. Need for caution. For example, factors which may mediate ideal treatment. Such as cardiac capacity for exercise, medication effects on tissue viability (long-term steroids). Thoughts about prognosis. For example, evidence from literature which supports the natural history and shapes the extent of intervention. Knowing that frozen shoulder has a self-limiting natural history of two years (plus) helps in making decisions about expectations for interventions.
Patient inclus ion and participation in decis ion making Patient-centred practice in manipulative and movement therapies, therefore, is driven by an inclusive clinical decision-making process whereby patients have the opportunity to consent and participate in decisions regarding the parameters of their therapy. The features of the Maitland Concept which underpin PRO Ms (patient reported outcome measures) and enhance patient participation in decision making are illustrated in the following examples of patient information:
• Patient-reported problems – Q uestion 1/ the main problem: I am having increasing dif culty
•
•
•
•
• • • • •
reaching to put my socks on in the morning due to groin pain and stiffness in my hip joint. An attention to detail as to what the patient is experiencing and where (body chart): deep, intermittent ache within the groin, ache radiating down the front of the thigh to the knee. H ow the problem is affecting them in their everyday life (their functional performance): every morning I struggle to put my socks on. I can only just reach the end of my foot with a lot of effort. M y hip feels very stiff and sore in the groin. I have stopped playing ve-a-side football because of the soreness afterwards and restriction during play. Their tolerance and acceptance of movement and activity (severity, irritability): becoming severe as they start to avoid activities and recreation. Less irritable as symptoms settle quickly after activity. What may be mediating their responses: fear of disability leading to surgery, frustration, anger and depression at not being able to do things (Ashby et al. 2009). Their C/ O and P/ E asterisks: (emphasis on individual, speci c and utility outcome measurement) (Box 1.2). H ealth and medical issues compounding their problems: Type 2 diabetes as a risk factor for peripheral vascular disease and neuropathy. The pathobiological nature of their condition (history) pattern: osteoarthritis of thhe hip (OA hip). Their physical status and functional capacity: hip exion 85 degrees stiff ++ (1) 5/ 10 (VAS – visual analogue scale). Their physical capacity against ideal (impairments): reduced range of movement in the hip, weakness in hip muscles.
Box 1.2 Asterisks as individual outcome measures C/O (1) Increas es when li ts knee towards ches t, very s ti and s harp pain in the groin (1) s ettles immediately the movement s tops . P/E Hip exion 85 degrees s ti ++ (1) 5/10 (VAS).
5
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• Risk factors to conditioning: poor general health and quality of life issues (social deprivation), access to support and socioeconomic priorities all contribute to compliance with healthy living options (McLean et al. 2011). • Their body’s capacity to inform (movement as a therapy and pain killer): understanding the health and pain-modulating bene ts of movement and exercise coupled with an appreciation of individual movement capabilities and de cits. • Their responsiveness and motivation to change: responders or non-responders to manipulative and movement therapies. This can be mediated by a number of extrinsic (personal and environmental) factors and intrinsic factors (pathobiology and nature of the problem). • Their evaluation of responses to interventions: recognition of changes in symptoms and signs during and between sessions. The primacy of clinical evidence supported and informed by research and experience-based knowledge, therefore, drives this patient-centred approach. For example, Sims (1999a) identi ed that in patients with OA hip X-rays reveal a common occurrence of down-and-in and up-and-out migration of the head of the femur. This knowledge may well support the clinical response of increasing range of hip exion in such patients when lateral or longitudinal caudad mobilizations are performed at the hip (Sims 1999b). Patient-centred practice enhances the evidencing of movement impairment and functional de cit. It con rms the presence of functional pathology (Stucki & G rimby 2007). It supports the application of appropriate interventions (Darzi 2008) and successful patient-focused outcomes where, for example, the patient can walk without pain, they feel better in themselves and their ability to do more is evident.
Patient-centred communication An attention to detail in obtaining reliable and meaningful answers to patient-centred questions will inform clinical practice and therapeutic decisions. Errors in communication, however, are known to have a big impact on the accuracy of clinical decisions (Maitland et al. 2005). As the physiotherapist tries to develop a broad and deep understanding of what is going on with the 6
patient using thoughtful communication strategies (H iggs & Jones 2000), the role of manipulative and movement therapies should be considered. Understanding the patient’s experiences will serve to make treatment decisions relevant and appropriate to individual problems. Physiotherapists must understand the neries of non-verbal communication to gain an understanding of how the patient is responding to the experience of pain and incapacity. The main source of information, however, comes from verbal exchanges with the patient. Care must be taken to employ strategies which ensure information gathered is as reliable and meaningful as possible and that questions asked have a single meaning and are unambiguous. These strategies, with examples, should include:
• Reasoning behind the question to be asked: (suf cient theoretical and clinical knowledge). For example, the patient is complaining about elbow pain which is sensitive to light touch. This suggests allodynia which is often associated with nerve injury. A common source of nerve entrapment is in the cervical spine so… • Wording the question: (what the therapist needs to know.) For example, to explore the possibility that the elbow pain has a neuropathic element to it I must ask the patient: ‘H ave you had or do you ever have any problems with your neck?’ • Hearing and understanding the words used in the patient answer: (follow up questions to be certain of the meaning). For example, the patient has told me that his elbow started hurting in the spring. A key word here is ‘spring’ so I must nd out what is the association between his elbow pain and spring. I must ask him ‘What was it that made your elbow start hurting in the spring?’ • Interpreting the answer: (clari es the answer to understand the patient’s symptoms rather than forming assumptions). For example, the patient has told me that he had to dig over his allotment in the early spring but has never had problems before. I could assume that the amount of digging was more than usual but should qualify my question if this was the case. I must ask ‘What was unusual about the digging this year?’ The patient told me that he had had to dig an area which had not been dug before and this was very rocky. H e felt the jarring
P a tie n t- c e n tre d p ra c tic e
rather than the amount of digging had caused his pain. • Relating the answer to the question: (has the question been completely answered in suf cient depth?). For example, in response to the question ‘Do you ever have problems with your neck?’ the reply ‘No, not now’ demands further explanation to determine whether any past episodes of neck pain could relate to the onset or development of the elbow pain. • D etermining the next question: (suf cient theoretical and clinical knowledge on which to base the next question irrespective of accuracy of patient answer). For example, to understand the signi cance of the neck problem, therefore, the immediate response question might be: ‘When was the last time you had problems with your neck?’ In parallel with an attention to questions being asked and qualifying responses the clinician must also pay attention to ensuring that the patient is:
• Hearing and understanding the question: (avoid using words which the patient cannot understand and avoid using questions which are biased towards a particular answer). For example, I want to use the same words that the patient uses in my follow-up questions and I want to avoid using leading questions. So I will not ask. ‘Is it right that the spondylosis in your neck was set off by the digging and this is sending pain into your elbow?’ Instead to ensure the patient understands the question and it is not leading him to a particular answer, (my hypothesis), I will ask, for example, ‘Do you feel your neck pain is connected to your elbow pain in any way?’ • Considering the reply: (the patient’s thoughts will affect what the question means to them and their memory of facts may be incomplete or inaccurate). For example, I must make sure that the question I ask does not have a double meaning and is not ambiguous. I must also be sure that I use key words to prompt the patient’s memory so that their recollection of events and experiences is as accurate as possible. So I will not ask ‘Where did you feel your rst pain?’ as the patient might wonder whether I mean his neck or elbow or he might think I mean to nd out whether he rst felt pain at the allotment or at home. I will ask
instead ‘When you jarred yourself digging in the rocky area can you recall what you felt?’ • Putting the answer into words: (be aware that the patient may lack experience in the health care environment which may in uence the response given). For example, I want to ensure that the patient has every opportunity to say what they are feeling and thinking rather than what they think they are expected to say. So I will not ask: ‘What did your doctor say was wrong with you?’ Instead I will ask: ‘What do you feel happened to you when you jarred yourself whilst digging?’
Unders tanding the body’s capacity to in orm and adapt Another feature of patient-driven clinical decision making is an understanding of the body’s capacity to inform (about the experience of injury, neuromusculoskeletal conditions and disease) (Box 1.3) and adapt (in uences of injury, disorder or disease on neuromusculoskeletal (NMS) functioning). If these capacities are understood then they open up a vast array of possibilities in:
• Being able to understand the patient experience, and • Being able to choose interventions which relate to those experiences. An understanding of the patient’s body’s capacity to inform or adapt begins immediately the therapist
Box 1.3 The body’s capacity to inform What the patient thinks is wrong with them Their experiences and their eelings The localization o their s ymptoms The impact on activities and participation (work and recreation) Res pons es to movement Reproducing s ymptoms or es tablis hing comparable s igns Res pons es during treatment E ects o treatment on s ymptoms and s igns Overall s atis action with outcome Maitland et al. 2005
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meets the patient and observes them. Examples of the body’s capacity to inform and adapt and therefore drive decisions are:
•
• The patient’s main problem: a re ection of the
•
•
•
•
•
•
whole experience (for example, a knee medial ligament sprain and how it impacts on the patient’s everyday life). What, or them, would be a success ul outcome?(For example, the patient is looking forward to experiencing no pain and discomfort in the knee and being able to return to playing football as soon as possible). The body chart: an expression of what the patient feels and how this is processed into symptoms (for example, soreness over the ligament, under the skin but sore to touch and intermittent pain). Behaviour o symptoms: what the patient can and cannot do because of their symptoms is a re ection of how the body informs and processes what activities and participation it is capable of based on the patient’s own knowledge and frame of reference from previous experiences (for example, a sharp pain over the knee ligament when twisting the leg means that the patient avoid twisting movements because they are too painful and it feels like the ligament will break). History o symptoms: if an injury causes or predisposes to symptoms, the body informs the patient about what has been damaged and by how much. Whether the body can help to identify a link between injuries and symptoms or not is another feature of the body’s capacity to inform (for example, the patient knew something had torn as soon as he was tackled from the side playing football last week. It hurt like a torn ligament and it swelled up almost straight away). Medical screening questions: usually the patient knows whether they are well or not, so questions about general health and well-being will help to inform about any personal mediators which may impact on the body’s response to physical therapies (for example, the patient feels well in himself, just a bit angry at the other player. H e says that he does take steroids to bulk up in the gym). Observation: recognition of protective posture is a re ection of the body’s capacity to adapt to 8
•
•
•
•
•
•
painful situations (for example, knee held in 10 degrees of exion in standing). Asking the patient to move to the f rst onset o pain (P1) or to the limit o available movement: this will be a re ection of the body’s capacity to inform about what is restricting movement (for example, knee extension minus ve degrees due to pain and apprehension). Asking the patient to show a unctional movement, which is affected by symptoms (functional demonstration), gives the patient an opportunity to use the body’s capacity to inform about how and how easily symptoms can be reproduced and it also gives the therapist an opportunity to analyze movement with reference to possible therapeutic interventions (Banks & H engeveld 2010). (For example, twisting the knee causing immediate pain and apprehension.) Structural di erentiation is, in effect, the body’s capacity to inform about tissue responses to movement and which tissues to in uence therapeutically (for example, stabilization of the tibiofemoral joint during the knee twisting eliminates the pain and apprehension). Passive testing of joints, muscle length and neurodynamic capacity, helps the therapist to understand how the body reacts to passive movement (for example; tibiofemoral anteroposterior accessory mobilization grade II, which is soothing; quads lag present due to inhibition; saphenous nerve length test not painful). Palpation: again is the body informing the therapist about tissue responses to handling and can it inform decisions about which interventions may be more effective? (For example, swollen, thickened medial ligament of the knee.) Assessment strategies also tap into the body’s capacity to inform about responses to interventions during and after treatments have been carried out (for example, since the mobilization, the pain is not so sharp when the patient twists his knee). D ecisions to stop treatment are often based on the patient’s feedback on whether interventions have been effective. This is often informed by the body’s capacity (for example,
C lin ic a l re a s o n in g
the patient can run and jump on the knee after several sessions; it still aches a bit but he thinks it has healed and he just needs to get t again).
The role o collaborative reas oning Collaborative reasoning is de ned as the nurturing of a consensual approach towards the interpretation of examination ndings, the setting of goals and priorities and the implementation and progression of treatment (Jones et al. 2006a). Collaborative reasoning (Jones et al 2006a) gives the therapist a framework which utilizes the body’s capacity to inform. Semistructured interviews give the patient an opportunity to impart information that is meaningful to them as individuals. Thoughtfulness in shaping semistructured questions will enhance collaboration between patient and therapist in coming to the correct (safe and effective) decisions about interventions. Examples of semistructured interview questions for the therapist to consider are:
• W hat is the problem you are having? • W hat are you feeling and where? • W hat effect is this feeling having on your everyday life? • W hat seems to change the feeling you have? • H ow did this feeling rst start? • Do you have any other health and well-being issues? To have a patient-centred meaning, collaboration should permeate all the therapeutic processes below:
• Information gathering during the subjective • • • • • •
examination. Planning the physical examination – the aims of the physical examination. Determining what to examine and by how much – identify the source of the symptoms, the cause of the source and contributing factors. Choice of interventions – what are the desired effects? Decisions on progression – what will produce graded improvements? Feedback on effects of interventions – what does the patient think? O utcomes meaningful to the patient – has the outcome achieved its goal?
Clinic al re as o ning Throughout the chapters of this edition of M aitland’s Peripheral M anipulation, contributors will detail the evidence and research underpinning clinical practice and how clinical practice can be explained in terms of specialist knowledge and skills. Clinical reasoning, therefore, is a process in which the therapist, interacting with the patient and signi cant others (e.g. family and other health care team members) structures meaning, goals and health management strategies based on clinical data, patient choices and professional judgement, knowledge and skills (H iggs & Jones 2000). Clinical reasoning should be viewed in relation to: • The brick wall concept • Patient-centred practice • Selection and progression of treatment • The expert clinician • Care pathways and best practice • The clinical practice framework of the Maitland Concept.
Clinical reas oning and the brick wall concept Physiotherapists are aware of a strong link between knowledge about the subject at hand and its application to clinical practice and how clinical practice is informed by research evidence. What this awareness is portraying is the application of the symbolic permeable brick wall model of thinking (Maitland et al. 2005) (Table 1.2). Leading commentators on manual therapy (Moore & Jull 2009) recognize that clinical reasoning assessment and clinical practice skills are a crucial nexus between the patient, the research evidence and successful clinical outcomes. The foundation of clinical reasoning lies in cognition – The thinking underlying clinical practice and metacognition – thinking about thinking (Jones 2012) and the ability to make decisions based on clinical evidence underpinned by a combination of research and experienced-based evidence. This is the essence of the brick wall concept. Clinical reasoning also requires an ability to explain clinical evidence and responses to examination and interventions in light of current knowledge. 9
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Table 1.2 The symbolic permeable brick wall and clinical reasoning
Theoretical knowledge and research evidence (Beeton et al. 2008)
Clinical evidence and skills
Evidence-based practice Biomedical sciences Clinical sciences Behavioural sciences Theoretical basis o neuromusculoskeletal (NMS) management The process o research
Clinical reasoning skills Assessment and management o patients with NMS disorders Communication skills enabling e ective assessment and management o patients with NMS disorders Practical skills with sensitivity and specif city o handling Commitment to the development o OMT practice
The brick wall allows the clinician the luxury of being able to make safe, effective therapeutic decisions even where there is an incomplete level of supporting evidence. The primacy of clinical evidence and use of clinical facts unhindered by diagnostically restrictive protocols helps the clinician to tailor clinical reasoning to the patient’s individual needs. Cox (1999) cited in Jones et al. (2006a) summed this up nicely by stating that: Scienti c method focuses on one variable at a time across a hundred identical … [Subjects] to extract a single, generalisable ‘proof ’ … Clinical practice deals with a hundred variables at a time within one … [Subject] … in order to optimize a mix of outcomes intended to satisfy the particular … [Subject’s] current needs and desires.
Theoretical Diagnosis • Pathology/structures • Biomedical engineering • Neurophysiology
10
The Maitland Concept, therefore, gives us a framework for effective clinical reasoning in the form of the symbolic permeable brick wall model of thinking (Fig. 1.2). By forming, in our mind, a permeable brick wall, our thoughts about clinical evidence and theoretical knowledge can be kept separate and yet can still interact with each other. This gives us a model which allows us to:
• Base our decisions primarily on the clinical evidence about dysfunction without being limited only to what is ‘known’ from research evidence and diagnosis – the primacy of clinical evidence. • Use our theoretical knowledge about the biomedical, behavioural and clinical sciences to back up clinical evidence helping to make features t. • Explain to the patient the meaning of clinical evidence from a biomedical, biomechanical, pathological or behavioural science perspective, therefore enhancing informed consent and collaborative decision making. • Accommodate all our personal knowledge, skills and attributes related to manipulative and movement therapies, all available evidence that we know of and our ability to analyze all in one place.
Patient-centred clinical reas oning Expanding on the idea of the primacy of clinical evidence and patient-centred practice, it is clear that the clinical side of the brick wall is supported by underpinning knowledge and emerging research from the theoretical side of the brick wall that
Clinical History Symptoms Signs
Fig ure 1.2 • The symbolic permeable ‘brick wall’: theoretical and clinical compartments. Reproduced with permission from Banks & Hengeveld 2010 .
C lin ic a l re a s o n in g
together drive clinical reasoning and decision making. Because the clinical process in physiotherapy has become patient driven (Department of H ealth 2010), opportunities have arisen to develop interventions based on patient needs and what, to them, would be a successful outcome. So, for example, if a patient cannot squat down because of a stiff knee caused by osteoarthritis, the main concern is not to cure the osteoarthritis but to enable the patient to squat more easily. In this way, the knee can be mobilized to increase range of movement leading to a successful outcome. Interventions, therefore, should be, and can be, directly linked, through clinical reasoning, to outcome needs more than ever before (Department of H ealth 2010). In effect, the domain of physiotherapy is no longer driven by disease but practice which focuses on ease or the desired effects of treatment (H engeveld & Banks 2005).
Clinic a l re a s oning a nd tre a tme nt s e le c tion a nd p rogre s s ion Clinical reasoning theory and practice (Jones et al. 2006a) has demanded that a broad and deep multidimensional range of physiotherapeutic interventions be available in clinical practice. More speci cally, the following examples demonstrate how a range of mobilization techniques can be selected according to clinical reasoning hypothesis:
• The source o symptoms – the use of compression to in uence pain emanating from the intra-articular component of a knee joint disorder (Noel et al. 2000). • The mechanisms driving the symptoms – neurodynamic sliders to overcome the allodynia generated from a mechanosensitive radial nerve in a patient with lateral epicondylalgia (Coombes et al. 2009). • Contributing actors – the patient with weakness of shoulder lateral rotation which improves immediately after the application of C5-6 joint mobilization techniques (Wang & Meadows 2010). • Functional demonstration (FD ) – a patient with anterior knee pain, when stepping onto a step, which has developed because of a stiff ankle. The FD can be utilized as a treatment position, with alignment correction and an anteroposterior mobilization of the talocrural
joint during step-up (Collins et al. 2004). This is illustrated in Figure 1.3. • Results o di erentiation strategies and merging examination with treatment – if a patient’s hip exion in supine lying increases in range beyond 90 degrees and becomes less painful when a medial glide is applied to the greater trochanter and activation of gluteus medius and maximus checks the pull of an overactive rectus femoris, then it is clear that this differentiation process also becomes the treatment of choice to achieve a shared outcome of pain relief and increased range of mobility. O f course, addressing the physical impairments alone in clinical reasoning is not enough when dealing with patients. A clear understanding of the nature of the person and how their frame of reference for illness affects their response to treatment must also be understood and taken into account. The context of mobilization and manipulation in supporting recovery of functional capacity and maximizing activity and participation must be understood if a clear role is to be identi ed. Passive mobilization and manipulation techniques can be a tool in helping clinicians to identify relevant sources, causes and contributing factors and to identify effective symptom and functional improving strategies. Such strategies can also be incorporated to prevent recurrences. Selection of mobilization as a therapeutic intervention has to be considered judiciously and based on: sound and reliable clinical evidence; what the patient needs and expectations are; and what research has come to tell us (Sackett et al. 1996). Such attention to detail in decision making and application of mobilization techniques can only serve to support and help achieve desired effects.
Clinic a l re a s oning a nd the e xp e rt c linic ia n The requirements for clinical reasoning at an expert level demand that the physiotherapist integrates but retains the independence of clinical evidence and theoretical knowledge to justify practice decisions to treat or not to treat a patient. Effective clinical reasoning is based on clinical competency. A novice or inexperienced clinician will reason strategically because they often lack the depth of knowledge and skill to link practice to theory and vice versa. Reasoning will be 11
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The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
A
B
D
E
C
Fig ure 1.3 • Ankle joint: A anteroposterior movement; B more localized talocrural; C more localized subtalar; D, E localized talocrural as treatment.
hypothetico-deductive or backward and a whole spectrum of hypotheses will be tested. An expert, on the other hand, will reason analytically because they have both deep and broad knowledge and skills portfolios to draw upon. Reasoning will be more inductive and based on pattern recognition. H ypotheses will be selective based on this recognition and a deeper ability to apply knowledge and skills. This does not mean that the expert will always get it right and make the correct decision but it should give more varied options for reaching 12
the end point more quickly. Maitland (1986) likened this process to a game of chess or contract bridge whereby plans can be made and changed as evidence emerges and until the nal goal is reached. The requirements for the transition from strategic to analytical reasoning, that is, from a novice to an expert, therefore, should include:
• An attention to detail in communication with the patient.
Exa m in a tio n
• A clear understanding of the context of the •
• •
•
•
•
patient experience and their frame of reference. A depth of knowledge and patient mileage whereby patterns of symptom presentation can be recognized and explained from knowledge of the clinical, behavioural and biomedical sciences and current primary research. Decision making around measurable clinical evidence of de cit in physical and or mental capacity and performance (C/ O asterisks). A depth and breadth of examination and intervention skills to call upon to con rm hypotheses and effect changes in functional de cit. Choosing reference standard screening and interventions for which there are clinical prediction rules (Beattie & Nelson 2006) or for which evidence in the literature supports their use in clinical practice (P/ E asterisks and treatment). A broad and deep understanding of outcome measures (C/ O and P/ E asterisks) to ensure interventions are being evaluated at all times (assessment, reassessment). Attributes which enhance analysis, appraisal and re ection upon clinical practice and the evidence available to support it.
Clinical reas oning, s pecif c care pathways and bes t practice Care pathways are commonly used in clinical practice to help guide decisions related to speci c conditions. The central route of the pathway, however, should always be reserved for clinical reasoning based on individual patient needs. In this way the physiotherapist is encouraged to use his or her own experiences, knowledge and skills to come to wellreasoned decisions about patient management. An example of a care pathway developed by a colleague of the author of this chapter highlights the pivotal role of clinical reasoning within an MSK (musculoskeletal) knee care pathway (Karanec 2010) (Fig. 1.4). Clinical reasoning also underpins best clinical practice frameworks which have been developed to support clinicians in their decision making. O ne such example is the C SP guideline on subacromial impingement syndrome (H anchard et al. 2004) where theoretical knowledge and clinical evidence
are matched to produce best practice guidelines from a physiotherapeutic perspective. Such frameworks should include:
• Background to the condition including • • • •
epidemiology, risk factors, diagnosis, de nition and mechanisms of injury or disorder. Clinical features common to the condition found from subjective and physical examination. Effective interventions or management strategies. O utcome measures appropriate for the condition. Research supporting practice.
In effect, this supports the clinician’s pattern recognition of a patient presentation as well as giving them the exibility in practice to make individualized therapeutic decisions.
Clinical reas oning and the clinical practice ramework o the Maitland Concept The Maitland Concept, therefore, offers a clinical practice framework with clinical reasoning and decision making at the centre and consists of:
• • • •
Information gathering (C/ O ) Planning appropriate physical examination Physical examination (P/ E) Evaluation and selection of appropriate manipulative physiotherapy or movement therapy interventions • Application of clinical skills in movement therapy • The delivery of meaningful patient education and information • A deep and broad portfolio of knowledge to interpret responses and actions. Box 1.4 details such a framework of practice underpinned by analytical reasoning.
Examinatio n Analytical assessment at the rst consultation is based on detailed examination ndings. This along with evaluation of manipulative and movement therapy is the keystone holding the Maitland Concept together (Maitland 1986). Text continued on p. 20 13
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:
C H AP TE R 1 The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
Exa m in a tio n
Box 1.4 A clinical reasoning form to support patient management How to p la n va rious s ta ge s o the the ra p e utic p roc e s s Although clinical reas oning is an ongoing proces s , with many tacit, implicit decis ions , it is es s ential to make s ome elements o the reas oning proces s explicit in order to s tructure and organize the proces s es below. The s tructuring o thinking bes t takes place in s ome o the s o-called critical phases o the therapeutic proces s : • • • • • • • •
Re erral ‘Welcoming’ o the patient Firs t s es s ion: during the s ubjective examination Firs t s es s ion: planning the phys ical examination (and f rs t exploratory treatment) Planning the s econd and third s es s ions Planning overall treatment (lates t in the third s es s ion) Planning retros pective as s es s ment Planning conclus ion o therapy
On re erral The biomedical diagnos is may already elicit hypothes es on pos s ible f ndings or phys iotherapy diagnos is by ollowing up on the ques tions : •
•
•
•
What do I know about the dis order: the natural his tory, which kind o treatment objectives may be neces s ary? ……………………………………………………………………………………………………………………………………... ……………………………………………………………………………………………………………………………………... Prediction o pos s ible f ndings : what can I expect to f nd in s ubjective and phys ical examination? ………………… ……………………………………………………………………………………………………………………………………... ……………………………………………………………………………………………………………………………………... How long does the treatment o s uch a dis order us ually take to e ect res ults ? ……………………………………….. ……………………………………………………………………………………………………………………………………... ……………………………………………………………………………………………………………………………………... What experiences have I had be ore with a (medical) re erral like this ? (For example, the diagnos is ‘coxarthros is ’ might be a movement dis order o lumbar s pine (Lx), s acroiliac joint, hip, or neurodynamic s ys tems .)……………... ……………………………………………………………………………………………………………………………………...
Welcoming the patient – in ormation and introduction phas e This phas e in uences the cours e o the f rs t s es s ions , and is relevant in enhancing the patient’s unders tanding o the s teps to be taken by the phys iotherapis t. As k the ollowing ques tions : Did the patient expect phys iotherapy as the treatment o choice or the problem? …………………………………..… ……………………………………………………………………………………………………………………………………........ Does the patient have an unders tanding o the phys iotherapis t’s s pecif c role in diagnos is and treatment o movement-related dis orders as complementary to biomedical diagnos is ? ………………………………………………….. ……………………………………………………………………………………………………………………………………........ Are there any evident is s ues with regard to privacy, the s etting, therapy, or therapis ts ? ………………………….…… …………………………………………………………………………………………………………………………….……………
During the s ubjective examination – regular s ummarizing o in ormation Whils t going through the s teps o es tablis hing the main problem – namely the body chart, 24-hour behaviour o s ymptoms , his tory and s pecial ques tions – it is us e ul to regularly sum m arize the in ormation provided by the patient. This s erves to validate and deepen your unders tanding o the patient’s problem, as well as enhancing the therapeutic relations hip: Main problem……………………………………………………………………………………………………..……………….. Body chart…………………………………………………………………………………………………………….…..……….. Symptom behaviour……………………...……………………………………………………………………………..…..…….. His tory o s ymptoms ………………………………………………………………………………………………………….…… Medical s creening ques tions ………………………………………………………………………………………………...……
15
C H AP TE R 1
The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
Box 1.4—cont’d A ter the s ubjective examination – prepare or phys ical examination This is an es s ential re ection and planning phas e. •
Re ect on the proces s o s ubjective examination: • •
• • •
•
Is the in ormation comprehens ive enough, particularly with regard to precautions ? Have you obtained us e ul parameters to per orm an in-depth comparis on o res ults at the beginning o the s econd s es s ion (reas s es s ment)? • Is relevant in ormation s till mis s ing? • What in ormation can be le t until the s econd s es s ion? Hypo the s e s – although certainly more hypothes es have been ormed during the s ubjective examination, a ew hypothes is categories have to be made explicit in this planning phas e: Sources (o all movement components pos s ibly involved; may als o include pos s ible s tructures involved).………… …………………………………………………………………………………………………………………………………...… Contributing actors (e.g. mus cle imbalance, pos ture, adaptive/maladaptive movement s trategies when pain in c re a s e s )……………………………………………………………………………………………………….………… ………………………………………………………………………………………………………………………………...…… Pathobiological proces s es : •
•
Tis s ue pathology……………………………..………………………………………………………………………...…….. ……………………………………………………………………………………………………………………………..…… • Stages o healing: know natural healing his tory o various s tructures (e.g. menis cus , mus cle, dis c, bone)…..… ……………………………………………………………………………………………………………………………..…… Neurophys iologic pain mechanis ms : •
•
Nociceptive mechanis ms …………..………………………………………………………………………………...……… …………………………………………………………………………………………………………………………….……. • Peripheral neurogenic mechanis ms ………………………………………………………………………………...………. …………………………………………………………………………………………………………………………….……. • Central nervous s ys tem proces s ing………………………………………………………………………………...………. …………………………………………………………………………………………………………………………….……. • Autonomic output mechanis ms …………………………………………………………………………………………...… …………………………………………………………………………………………………………………………….……. • A ective (cognitive/emotional mechanis ms ……………………………………………………………………………….. …………………………………………………………………………………………………………………………….……. Contraindications to examination and treatment procedures – precautions to examination and treatment procedures as determined by the ques tions : Is the problem s evere/irritable, yes or no? …………………………………………………………………..……..…….. Are there any actors o ‘nature o the problem’ to be res pected? ………………………………………..…………… Pathobiological proces s ……......………………………………………………………………………………………..…… Co-morb id ity………………………………………………..………………………………….………………….....……… Stages o healing……………………………………………………………………………………………………..………… Stage and s tability o the dis order (Hx)…………………………………………………………………...…………..…… Nature o the pers on’: (lack o ) conf dence to move……………..…………………………………………………..…..
Planning procedures o phys ical examination •
Anticipation and extent o phys ical examination: Do you think you will need to be gentle or moderately f rm with your examination procedures ? Do you expect a ‘comparable s ign’ to be eas y/hard to f nd? Explain why………………………………. What movements do you anticipate to be comparable? Are there any pos itions or movements that need s pecif c cons ideration during P/E (e.g. prone lying)?
16
Exa m in a tio n
Box 1.4—cont’d Which s ymptoms would you like to reproduce? Are there any s ymptoms which you would NOT want to produce (e.g. dizzines s , paraes thes ia)? Tes ts to ons et o P1/care ully beyond P1 (‘Trus t 1’)/to Limit o movement (L)………..……………………...……… ………………………………………………..………………………………………………………………………………..... Initial tes ts /s tandardized tes ts , without overpres s ure/s tandardized tes ts with overpres s ure/‘i neces s ary’ …...… …………………………………………..…………………………………………………………………………………….… •
•
Phys ical examination, reas s es s ment and f rs t exploratory treatment: Ins p e c tion/obs e rva tion……………………………………………………………………………………………………… ……………………………………………………………………………………………………………….....……………… Functional demons tration (and di erentiation)……………………………………………………………………………… Active tes ts (including overpres s ure) – may need ‘i neces s ary’ tes ts ? ………………………………………………… …………………………………………………………………………………………………………………………….....… Is ometric and mus cle activation tes ting? …………………………………………………………………………………… ……………………………………………………………………………………………………………………….………… Neurological examination? (Conduction? )…………………………………………………………………………………… ………………………………………………………………………………………………………………………….……… Pas s ive tes ts and reas s es s ment: neurodynamic tes ts ; pas s ive components ; other tes ts (e.g. ins tability tes ting) …………………………………………………………………………………………………………………………… Plan when you intend to per orm reas s es s ment procedures
During phys ical examination procedures During the application o phys ical examination procedures – particularly a ter the application o a unctional demons tration tes t, including di erentiation procedures , and a ter per ormance o active tes ts – a ‘brie apprais al’ is o ten neces s ary: S hall I continue with the physical exam ination procedures as planned or do I need to change the course of the e xam ination?… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … .. …………………………………………………………………………………………………………………………………………
A ter the f rs t s es s ion – prepare or the s econd treatment s es s ion This is an es s ential re ection and planning phas e. • • • • • • • •
•
•
Re ect upon/s ummarize all the relevant in ormation o the s ubjective, phys ical examination, exploratory treatment and reas s es s ments Hypothes es – all hypothes es need to be made explicit now, including recons ideration o thos e hypothes es that have been made explicit a ter the s ubjective examination Pathobiological proces s es , including neurophys iological pain mechanis ms …………………………………………… …………………………………………………………………………………………………………………………………… Sources o the movement dys unction and pain, including pos s ible s tructures involved…………………………… …………………………………………………………………………………………………………………………………… Precautions and contraindications …………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… Level o dis ability (expres s ed in terms o impairment, activity limitations and participation res triction)…………… …………………………………………………………………………………………………………………………………… Contributing actors (pos ture, mus cle balance, working patterns , f tnes s and health levels , etc.)…………………… ………………………………………………………………………………………………………………………………… Individual illnes s experience (belie s , attitude, emotions , behaviour, s ocial in uences , values , habits , coping s tyle, etc.), including s pecif c needs o the patient……………………………..........…………………………………………… …………………………………………………………………………………………………………………………………… Management: s hort-term and long-term objectives , interventions (and alternative choices to reach the objectives )…………………………....…………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… P rognos is ………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………
17
C H AP TE R 1
The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
Box 1.4—cont’d •
Do I recognize a clinical pattern? …………………………………………………………………………………………….. • Are pathobiological proces s es at the background o the movement dis order (e.g uns table dis c problem, lumbar s t e n o s is )? …………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… • Is it a one component or multicomponent movement dis order (e.g. pain in area o s houlder with more components involved s uch as neck, thorax, glenohumeral joint, motor control and neurodynamic s ys tem)? …................………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… • Is a multidimens ional approach to treatment neces s ary, including cons ideration o cognitive, emotional and behavioural elements ? ……………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………
Cours e o the s econd s es s ion •
Which s ubjective examination (C/O)*** do you want to reas s es s ? (Know the indicators o improvement!)………… …………………………………………………………………………………………………………………………………… • How do you want to complete the C/O? (Main problem ; body chart; 24-hour behaviour; Hx, special q ue s tions .)… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … . …………………………………………………………………………………………………………………………………… • Which P/E*** do you want to reas s es s ? ……………………………………………………………………………………… …………………………………………………………………………………………………………………………………… • Which tes ts do I need to carry out to complete the P/E? (Think of things like elem ents of observation, active testing, neurological exam ination, m uscular testing, which you would have liked to have exam ined in the rst session, but for som e reason you did not do so.)… … … … … … … … … … ……………………………………………………………………………………………………………………………………… • Other movement components : which component do you want to explore urther? Screening tes ts – s tate which tes ts AND when you will per orm them as reas s es s ment procedures …………………………………………………… …………………………………………………………………………………………………………………………………… • Which treatment interventions , including which*** or reas s es s ment? …………………………….……………………. …………………………………………………………………………………………………………………………………… • Which components and elements would you like to inves tigate and/or treat in the third s es s ion? ………………… …………………………………………………………………………………………………………………………………… • What will you do i : 1. The patient is better? …………………………………………………… 2. The patient’s condition is unchanged? ……………………………………………….. 3. The patient may be wors e? Cons ider C/O and P/E f ndings and pos s ible coping s trategies .
Planning and preparation o the third s es s ion Similar to the planning o the s econd s es s ion – a s ummary o main in ormation rom the f rs t and s econd s es s ions is needed (f ndings , res pons e to treatment): • •
Recons ider all hypothes is categories : have they changed? (May relate back to s heet us ed a ter f rs t s es s ion.) Plan o concrete cours e o the third s es s ion – needs to include more treatment options and, i applicable, s el -management s trategies .
Planning and preparation o the ourth and cons ecutive s es s ions Similarly to planning o the s econd and third s es s ions – cons ider retrospective assessm ent at regular intervals (every ourth s es s ion).
18
Exa m in a tio n
Box 1.4—cont’d A ter three s es s ions – def ning comprehens ive treatment objectives and s etting priorities : planning or the end-point In this phas e it is o ten neces s ary to cons ider the ollowing ques tions , in order to plan treatment comprehens ively, with s hort-term and long-term objectives as well as meaning ul interventions : 1. relating to the individual illnes s experience •
Which impairments have I ound; which activities are limited; which activities and elements rom participation may be us ed as outcome meas ures ? ……………………………………………………………………………………. ………………………………………………………………………………………………………………………………… • Illnes s behaviour: adaptive/maladaptive? ………………………………………………………………………………… ………………………………………………………………………………………………………………………………… • How much dis tres s does the patient s eem to have? …………………………………………………………………… ……………………………………………………………………………………………………………………………… • Are there any pathobiological proces s es which I need to res pect? 2. Relating to an optimum s tate o health with regard to movement unctions – which can be cons idered as ‘planning for the end-point’ – as k yours el , how clos e/ ar does the patient s eem to be to an optimum s tate o health with regard to movement? • • • • • •
Normalizing impairments as ar as pos s ible……………………………………………………………………………… ………………………………………………………………………………………………………………………………… Guiding the patient towards the experience o conf dence in us e o the body again……………………………… ………………………………………………………………………………………………………………………………… Prophylactic meas ures ……………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… Sel -management s trategies , implementation o coping s trategies to learn to control s ymptoms ……………… ………………………………………………………………………………………………………………………………… Optimizing level o activity and participation, f tnes s levels …………………………………………………………… ………………………………………………………………………………………………………………………………… Towards the end o the treatment s eries – f nal analytical as s es s ment……………………………………………… …………………………………………………………………………………………………………………………………
Review o the whole therapeutic proces s , including s tatements o the patient regarding the individual learning proces s • • • •
•
• •
Re ection on the overall therapeutic proces s : which interventions were e ective? ………………………………….. …………………………………………………………………………………………………………………………………… Re ection on the learning proces s : what was es pecially important to the patient – what has been learned? ……. …………………………………………………………………………………………………………………………………… The e ectivenes s o any prophylactic meas ures and s el -management interventions ………………………………… …………………………………………………………………………………………………………………………………… Pros pective view: anticipation o pos s ible di f culties and s trategies to enhance long-term compliance with a regard to advice, s el -management meas ures and exercis es …..............………………………………………………………… …………………………………………………………………………………………………………………………………… Compliance enhancement s trategies : which s el -management interventions are es pecially benef cial? In which s ituations would the patient anticipate any di f culties in the uture? Which activities or exercis es would the patient res ume in the cas e o recurrence o s ymptoms ? ………………………………………...............………………………… …………………………………………………………………………………………………………………………………… Sugges tions or any medical or other meas ures that s hould be carried out……………………………………………… ………………………………………………………………………………………………………………………………… Prognos is on pos s ible remaining unctional def cits in impairment, activity and/or participation levels …………… ……………………………………………………………………………………………………………………………………
19
C H AP TE R 1
The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
The key features of the examination are:
• Communication during the subjective • • • • • •
examination The subjective examination interview strategies Manual testing Reassessment during examination The order and structure of examination Reasoning strategies during examination Planning and performing physical examination.
Communication during the s ubjective examination An attention to detail in communication and information about the patient’s experience of their problems (C/ O asterisks) should focus upon:
• What they feel and where (expressed on a body • • • •
chart) H ow they are affected in their daily life H ow and when the problems started Whether the problems are new, ongoing, recurrent or related to other problems What health and medical risk factors may impact on therapeutic interventions.
The s ub je c tive e xa mina tion-inte rvie w s tra te gie s In the subjective examination the clinician needs to develop a range of interviewing strategies that suit the way that the patient can express themselves most effectively. In most cases a semistructured interview with open questions is most appropriate as this, collaboratively, gives the patient an opportunity to narrate their account of their problems and, in addition, gives the therapist an opportunity to gather therapeutically meaningful information. In other cases it may be clear that structure to the interview is not appropriate. There are instances when the patient should be allowed to narrate their account unhindered by questions which may distract their train of thought and inhibit their ability to recount all the necessary information. The interview, therefore, should be unstructured and more of a discussion with a shared consensus on further actions. There are times, however, when a very structured and directed interview is necessary. Although this is not patient-centred and collaborative it gives 20
the therapist an opportunity to gather speci c information where the patient may have learning or communication dif culties. This exibility in interview and the further analysis and planning should, at all times, have a range of recognized clinical reasoning strategies embedded within them.
Manual tes ting Manual examination, which is based on wellestablished tests with functional utility, will help to provide clinical measures and features (P/ E asterisks) which will help to establish or con rm:
• Physical impairments • Dysfunctions (activity limitations, participation • • • •
restrictions) (WH O 2001) The source of the patient’s symptoms Contributing factors Mechanisms of symptom production Possible treatment techniques or intervention strategies (Jones et al. 2006a, 2006b).
Re ection on information and tests will help in the planning and decision making related to the role of manipulative and movement therapies. Selection and progression of interventions can then be based on the desire to support the patient in managing or overcoming their movement impairments, limited daily tasks and restricted work or recreation.
Reas s es s ment during examination Further and repeated assessment and reassessment of the effects of interventions on the patient’s reported problems and their functional status (C/ O and P/ E asterisks) will guide any need to progress or change treatment (H engeveld & Banks 2005). In this way there is always a move towards a successful outcome, a partially successful outcome, or an outcome where it is clear that the patient and their condition requires management beyond the scope of manipulative and movement therapy treatments. Take the patient (a young runner, 24 years old) with a tight groin when striding out. Thomas’s test reveals tightness of the iliotibial band (ITB). O n further investigation, activation of psoas did not alter the ITB length through reassessment but activation of gluteus medius led to a physiological lengthening of the ITB as evidenced by reassessment of Thomas’s test. Interventions could then be
Exa m in a tio n
directed accordingly to activation of a weak gluteus medius. Consequent examination and reassessment led to recognition of improvement in running. The message here is that the discipline of assessment and reassessment drives and evidences interventions and appropriate outcomes.
The order and s tructure o examination The format, order and structure of examining patients with NMS or any condition is well recognized (Boxes 1.5, 1.6 and 1.7) (H engeveld & Banks 2005).
Box 1.5 Summary: subjective examination The s ubjective examination may be cons idered ‘an interrogation with em pathy’. It indicates the depth o ques tioning and enables the therapis t to get an impres s ion o patients ’ pers onal experiences o their dis orders and the impact on their lives . The s ubjective examination ollows s everal objectives : •
Determination o the problem o the patient, rom the patient’s pers pective • Subjective parameters which s erve reas s es s ment procedures (s ubjective as teris ks ) • Determination o precautions and contraindications to phys ical examination and treatment procedures • Generation o multiple hypothes es , to be tes ted during phys ical examination procedures and treatment interventions . The s ubjective examination can be divided into f ve parts : •
‘Kind’ o dis order – es tablis hing the main problem and perceived dis ability • Site o s ymptoms – body chart • Behaviour o s ymptoms and level o dis ability • His tory (current, previous ) • Special ques tions . S ystem atic recording o the in ormation obtained is a valuable learning experience as it helps to identi y the es s ential elements or urther examination and treatment. Committing the in ormation and thoughts to paper is an invaluable aid in the development o cons cious clinical reas oning proces s es . Writing in ormation s ubs equently on the s ame parts o , or example, the body chart may enhance s el -monitoring s kills or s ubs equent s es s ions and to enable you to as s es s i important in ormation is mis s ing. Us ing as teris ks in the recording o in ormation is es s ential. This s erves two unctions : 1. It identif es thos e points which can be us ed in the reas s es s ment o the patient’s progres s 2. It s erves as a teaching proces s , to latch onto in ormative and s ignif cant words . This s peeds up the proces s and makes it more precis e. It is important that the as teris k be us ed at the ins tant o
recording the in ormation (‘asterisk as you go along’), not on completion o the examination as a retros pective exercis e. This aids the therapis t to be immediately aware o relevant in ormation to be ollowed up during later s tages in the therapeutic proces s . ‘Making features t’ is an important principle o the Maitland Concept: • Ques tions need to be as ked to as s es s i the eatures o the his tory f t with the behaviour and localization o the s ymptoms . I s evere dis abling s ymptoms have been caus ed by a trivial incident, extreme caution is needed: ‘the eatures do not f t’ and cannot be explained by the movement behaviour o the patient or any s tructural changes (e.g. os teoarthritic changes ). In s uch cas es the patient may need to be re erred to a medical practitioner or urther inves tigation • Furthermore, the Concept als o as s es s es whether the behaviour o the s ymptoms f ts with a recognizable s yndrome or pathology. This includes the diagnos is o patterns o biomedical pathology or movement dis orders • This in ormation will be linked with examination f ndings and reactions to therapeutic interventions which may aid the novice in the development o clinical patterns , thus contributing to the experiential knowledge bas e. With s ome patients , the experienced phys iotherapis t may engage in orms o narrative reasoning in order to get a deeper unders tanding o the patient’s belie s , thoughts , eelings and earlier experiences with the dis order and the various health care practitioners . I the phys iotherapis t decides to ollow a more narrative approach to the examination procedures rather than a procedural approach, it is es s ential to keep an overview o the res t o the in ormation that needs to be gained rom the s ubjective examination, as the patient requently may engage in a des cription o the previous his tory and all the treatment interventions which have been undertaken s o ar. However, or many patients it may be a healing experience i they are allowed f rs t to give their own account o their experience without being interrupted by ques tions which s uit phys iotherapy diagnos is .
Kleinmann 1988, Greenhalgh & Hurwitz 1998, Thomson 1998
21
C H AP TE R 1
The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
Box 1.6 Planning sheet as preparation of the physical examination A) Re e c tio n o the s ubje c tive e xaminatio n (Verif cation that the s ubjective examination is complete in order to be able to s tart the phys ical examination and to per orm a reas s es s ment o s ubjective parameters – as teris ks – in s ubs equent s es s ions .) 1. Summary o the main in ormation o the s ubjective examination: ……………………………………………………………………………………………………………………………………… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … .......… … … … … … … 2. Agreed treatment objectives bas ed on the f ndings o the s ubjective examination: ……………………………………………………………………………………………………………………………………… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … .......… … 3. Which s ubjective parameters (as teris ks ) will be us ed in s ubs equent s es s ions as part o the reas s es s ment procedures ? Des cribe the parameters in s u f cient detail: ……………………………………………………………………………………………………………………………………… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … .......… … 4. Has the s ubjective examination been s u f ciently comprehens ive to be able to make conf dent s tatements and to develop hypothes es with regard to precautions and contraindications to phys ical examination procedures ? (Check in ormation o ‘Q1’, body chart, behaviour o s ymptoms , Hx, SQ): ……………………………………………………………………………………………………………………………………… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … .......… … …
B) Hypo the s e s Dominant neurophys iological s ymptom mechanis ms Lis t the s ubjective in ormation which s upports the hypothes es o the various neurophys iological s ymptom mechanis ms : • • • •
Input mechanis ms – nociceptive s ymptoms : … … … … … … … … … … … … … … … … … … … … … … … … … … … ..… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … ...… … … … Input mechanis ms – peripheral neurogenic mechanis ms : ………………………………………………………………… ……………………………………………………………………………………………………………………………......…… Proces s ing – central nervous s ys tem mechanis ms and/or cognitive/a ective/s ociocultural in uences : …………… ……………………………………………………………………………………………………………………………......…… Output mechanis ms – motor and autonomic res pons es : ………………………………………………………………… ………………………………………………………………………………………………………………………………..……
Sources o s ymptoms /impairments Lis t all the possible s ources o any part o the patient’s s ymptoms that m ust be examined: • • • • • •
J oints underlying the s ymptomatic area(s ): …………………………………………………………………………………… …………………………………………………………………………………………………………………………..……… J oints re erring into the s ymptomatic area(s ): ……………………………………………………………………………… ……………………………………………………………………………………………………………………………..……… Neurodynamic elements related to s ymptoms and dys unction: ………………………………………………………… ……………………………………………………………………………………………………………………………..……… Mus cles underlying the s ymptomatic area(s ): ………………………………………………………………………………… ……………………………………………………………………………………………………………………………..…… So t tis s ue s tructures underlying the s ymptomatic area(s ): ………………………………………………………………… ……………………………………………………………………………………………………………………………..…… Others : ……………….…………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………..…
22
Exa m in a tio n
Box 1.6—cont’d Contributing actors Which as s ociated actors may be contributing/caus ing/maintaining the problem and dis ability? •
Neuromus culos keletal: ………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… 1. Reas ons why the joint/mus cle or other s tructure has become s ymptomatic/reas ons why the dis order may recur (e.g. pos ture, mus cle imbalance, mus cle coordination, obes ity, s ti nes s , hypermobility, ins tability, de ormity in neighbouring joints , etc.): …………………………………………………………………………………………………… 2. The e ect o the dis order on joint s tability: • Medical actors : ………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… • Cognitive actors : ……………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… • A ective actors : ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… • Behavioural actors : …………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………… When do you expect to incorporate thes e actors in phys ical examination procedures (immediately/in later s es s ions ? ). Speci y: ………………………………………………………………………………………………………………………………
Precautions and contraindications to examination procedures and treatment interventions •
Are the s ymptoms s evere/irritable? Yes /No a. Speci y your ans wer with examples rom the s ubjective examination: ………………………………………………………………………………………………………………………………… b. Is it pos s ible that ongoing s ens itivity takes place due to central nervous s ys tem s ens itization or avoidance behaviour? Speci y your ans wer: ………………………………………………………………………………………… • Does the nature o the problem indicate caution? Yes /No a. Tis s ue pathology: …………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………… b. Other pathological proces s es (e.g. os teoporos is ): ……………………………………………………………………… ……………………………………………………………………………………………………………………………… c. Stages o tis s ue healing: …………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… d. Stage o the dis order (Hx) (progres s ive/regres s ive/s tatic): ……………………………………………………………… ……………………………………………………………………………………………………………………………… e. Eas y to provoke exacerbation or acute epis ode (s tability o dis order): ……………………………………………… ……………………………………………………………………………………………………………………………… . Conf dence to move/extreme guarding o the patient: ………………………………………………………………… ………………………………………………………………………………………………………………………………… What are the implic atio ns o this ans we r with re g ard to the e xte nt o the phys ic al e xaminatio n?: …………… ……………………………………………………………………………………………………………………………………… • Management – objectives /i treating local movement impairment – P or R a. Which s hort-term or long-term goals o treatment are purs ued? : …………………………………………………… ………………………………………………………………………………………………………………………………… b. I pas s ive mobilization is a treatment option, do you expect to be treating pain, res is tance but res pecting pain, res is tance or res is tance to provoke ‘bite’? : ……………………………………………………………………………… ………………………………………………………………………………………………………………………… c. Are there any precautions or contraindications which need to be res pected (‘nothing at the price o ’…)? : …… …………………………………………………………………………………………………………………………… d. What advice s hould be included and/or what meas ures would you us e to prevent/les s en recurrences and provide the patient with a s ens e o control over the s ymptoms ? : …………………………………………………… …………………………………………………………………………………………………………………….....…………
23
C H AP TE R 1
The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
Box 1.6—cont’d C) Pro c e dure s o e xaminatio n Antic ipatio n o the re s ults o e xaminatio n pro c e dure s Do you think you will need to be gentle or moderately f rm with your examination procedures ? : ……………………… ……………………………………………………………………………………………………………………………………… Do you expect a ‘comparable s ign’ to be eas y/hard to f nd? (i hard to f nd, ‘ unctional demons tration tes ts ’ and ‘i neces s ary tes ts ’ may be planned in advance, hence s aving time). Explain why: ………………………………………… ………………………………………………………………………………………………………………………………………… What movements do you anticipate to be ‘comparable’? : …………………………………………………………………… ………………………………………………………………………………………………………………………………………… Might there be any pos itions or movements that need s pecif c cons ideration during phys ical examination? (e.g. lying in prone pos itions ): ………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………
Exte nt o e xaminatio n pro c e dure s Any pos itions you may need to avoid in the examination? (e.g. prone lying): ……………………………………………… ……………………………………………………………………………………………………………………………………… Which s ymptoms would you like to reproduce? : ……………………………………………………………………………… ………………………………………………………………………………………………………………………………………… Are there any s ymptoms which you would not want to produce? (e.g. dizzines s , paraes thes ia): ……………………… ………………………………………………………………………………………………………………………………………… To what extent may you provoke s ymptoms ? (lis t this or each relevant s ymptom area). Until the ons et o P1/ care ully beyond P1 – maybe exploring ‘Trus t1’/move to the limit o the tes t movements : ………………………………………………………………………………………………………………………………………… Number o tes ts you will be per orming: ………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………
Small numbe r o initial te s ts (ac tive mo ve me nts s ho rt o limit)/s tandard te s ts witho ut o ve rpre s s ure (ac tive limit o mo ve me nt)/s tandard te s ts with o ve rpre s s ure (ac tive limit plus o ve rpre s s ure )/‘i ne c e s s ary’ (o r ‘whe n applic able ’) te s ts •
•
• •
Which components do you examine and which tes ts (including reas s es s ment procedures ) will you per orm in the rst session? ……………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………… Which components do you expect to examine in the second session? (And with which tes ts ? ): …………………… ……………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… Which components or contributing actors do you expect to examine in later s es s ions ? (And with which tes ts ? ): ……………………………………………………………………………………………………………………………………… Sequence o examination procedures o the f rs t s es s ion: ………………………………………………………………… ………………………………………………………………………………………………………………………………… •
Obs ervation: ………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………
•
Functional demons tration tes t and di erentiation: ……………………………………………………………………… ………………………………………………………………………………………………………………………………
•
Active movement tes ts (s peci y which): …………………………………………………………………………………… ………………………………………………………………………………………………………………………………
•
Is ometric tes ts (with which purpos e? ): …………………………………………………………………………………… ………………………………………………………………………………………………………………………………
•
Speci y which tes ts : ………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………
24
Exa m in a tio n
Box 1.6—cont’d •
Are any s pecial tes ts indicated? : …………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… a. neurological examination (conductivity): ……………………………………………………………………………… ……………………………………………………………………………………………………………………………… b. others (e.g. ins tability tes ting): ………………………………………………………………………………………… ………………………………………………………………………………………………………………………………
•
Neurodynamic tes ting: ……………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………
•
Palpation and pas s ive movement tes ting: ………………………………………………………………………………… ……………………………………………………………………………………………………………………………… a. acces s ory movements (s peci y joint pos ition; which acc. mvts ): ………………………………………………… ……………………………………………………………………………………………………………………………… b. phys iological movements : ……………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… c. others : ………………………..…………………………………………………………………………………………… ……………………………………………………………………………………………………………………………… Whe n do yo u plan to pe r o rm re as s e s s me nts during the P/E pro c e dure s ? (Indicate this with a double line behind the above-mentioned tes t procedures .)
The aim of the subjective part of the examination is to establish parameters of the disorder from the patient perspective, from medical records and from medical screening reports. H ow the disorder presents will generate a range of hypotheses (Jones et al. 2006a) which will in uence further clinical examination and choice of therapeutic interventions. Planning of the physical examination then helps the physiotherapist to focus on priorities. The main aim of physical examination is to identify or con rm physical impairments related to the patient’s symptoms. O ften subjective examination merges with physical examination which in turn merges with treatment and reassessment. The interrelationship between examination, planning, treatment and reassessment can be seen in the following example. A patient with anterior knee pain says that he is having great dif culty climbing stairs because of his pain. This is an ideal opportunity for the therapist to ask the patient to ‘show me’. Immediately, relevant physical examination has been identi ed. The therapist then has the opportunity to analyse the activity of stepping up to the point of reproducing pain. Alignment or positional faults can be identi ed and adaptive faults can be seen. Mis ring of
the quadriceps can be observed. Restriction in joints such as the ankle can be observed. Changes can be made to these faults or adaptations to assess whether changes in pain or range responses occur. Loading of different structures can con rm the source of the symptoms. Interventions such as medial glide of the patella resulting in decrease of pain and increase force in step-up can then be employed as treatment in functional positions. Reassessment of the step-up will then evaluate whether such timely interventions have had an immediate effect on the functional de cit. Reassessment on subsequent visits will help to evaluate whether the treatment in the functional position and correction of alignment faults has led to sustainable gains. This integrated approach will then support further investigation of the impact of the stiff ankle as a contributing factor or further a eld to pelvic stability and lumbar mobility/ stability, or as analysis of the functional movement determines. Boxes 1.5–1.9 give an overview of how the subjective examination may be structured, how to plan the physical examination and the key details of what the physical examination may entail. Under speci c conditions it will be necessary also to investigate for presence of red and yellow ags. 25
C H AP TE R 1
The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
Box 1.7 General overview of physical examination procedures Ob s e rva tion • •
General obs ervation, local obs ervation Watch or patient’s willingnes s to move the s tructures
P P (p re s e nt p a in) •
Correction o protective de ormities
Func tiona l d e mons tra tion – unc tiona l te s ts , inc lud ing d i e re ntia tion
Brie apprais al
Sp e c ia l te s ts (e.g. neurological examination, ins tability tes ting, vas cular tes ting) Ne urod yna mic tes ting (may be per ormed as part o pas s ive tes ting and component analys is ) P a s s ive movements (as component analys is , including regular reas s es s ment) • •
Movement diagram Acces s ory movements (def ne pos ition in phys iological range) Phys iological movements (e.g. F/Ad hip, s houlder quadrant) Mus cle length tes ts
Brie apprais al
Ac tive move me nts
•
•
•
•
Gait analys is , other active tes ts in weight-bearing (s itting, s tanding) Active phys iological movements : • • • • •
overpres s ure ‘i neces s ary’ tes ting/‘when applicable’ tes ting tes t movements as ter, repeated, s us tained, changing rom one end to the other combined movements compres s ion, dis traction
Is ome tric te s ts • •
Function – s trength, coordination Symptom reproduction
Ac tive te s ts o othe r c omp one nts in the p la n • •
J oints pos s ibly re erring into the area J oints above and below – movement quality as a contributing actor to movement in the main component?
P a lp a tion •
Temperature, s welling, was ting, s ens ation, pos ition o s tructures , tendernes s o s tructures • So t tis s ue examination (e.g. trigger points , mus cle ins ertions ) • Nerve palpation (Palpation o temperature/s welling may be done during obs ervation and regularly during P/E; palpation o tis s ue tendernes s /pos itions may be per ormed be ore pas s ive tes ting.)
Check cas e records and radiographs Highlight m ain ndings with asterisks Plan reas s es s ments (when, which in ormation/ tes ts ) Warning, ins tructions and recommendations
Box 1.8
Box 1.9
Red ags
Summary of yellow ags
• • •
•
• • • • • • • • •
Age o ons et <20 or >55 years Violent trauma Cons tant progres s ive, non-mechanical pain (no relie with bed res t) Thoracic pain Pas t medical his tory o malignant tumour Prolonged us e o corticos teroids Drug abus e, immunos uppres s ion, HIV Sys tematically unwell Unexplained weight los s Wides pread neurology (including cauda equina s yndrome) Structural de ormity Fever
Moffet & McLean 2006
26
•
• •
A belie that back pain is harm ul or potentially s everely dis abling Fear-avoidance behaviour (avoiding a movement or activity due to mis placed anticipation o pain) and reduced activity levels Tendency to low mood and withdrawal rom s ocial interaction Expectation o pas s ive treatment(s ) rather than a belie that active participation will help.
Moffet & McLean 2006
Exa m in a tio n
What should be emphasized, therefore, about the examination process is that it should be appropriate, relevant, comprehensive, logical and methodical. The patient should not be expected to t the therapist’s examination preferences. O n the contrary, the examination should adapt to the needs of the individual patient.
Box 1.10 Reasoning strategies Dia gnos tic re a s oning Pres enting clinical eatures leading to the ormation o a diagnos is related to hypothes is categories : impairment, pathobiology, pain mechanis ms and contributing actors .
Na rra tive re a s oning
Reas oning s trategies during examination
As s es s ment and reas oning related to the patient’s belie s , culture and illnes s experience.
Re a s oning a b out p roc e d ure
Edwards et al. (2004) in a qualitative design study established a range of clinical reasoning strategies utilized by physiotherapists throughout an episode of care. These strategies also support exibility and provide a clinical reasoning model on which therapists can explore and shape their clinical care pathway. Box 1.10 outlines clinical reasoning strategies used by physiotherapists in clinical practice (Edwards et al. 2004).
Reas oning underpinning decis ions regarding examination and treatment procedures bas ed on clinical evidence and s upporting theoretical and res earch knowledge.
Inte ra c tive re a s oning Reas oning underpinning the s trategic meas ures taken to optimize the therapeutic relations hip.
Colla b ora tive re a s oning A cons ens ual approach to decis ions related to goals , examination and management.
Re a s oning a b out te a c hing
Planning and per orming the phys ical examination
Reas oning underpinning teaching s trategies s elected and implemented.
Planning of the physical examination should be collaborative and ethical. This means that, with expert advice and information the patient is empowered to take ownership of their therapeutic care and share decisions with their physiotherapist. There should be collaboration, therefore, around what needs to be examined and how. H ow examination will be interpreted and what options for intervention, treatment and management will emerge. Through planning, physical examination should be logical, appropriate and above all safe and risk reduced. Physical examination should be designed around the patient’s needs, such as: • Movements or activities: which reproduce their symptoms or identify movement impairments; which take into consideration movement tolerance or acceptance (severity, irritability, nature); and which can be reassessed reliably. It is important that these movements or activities are functionally relevant to the individual and relate to their everyday activities.
Reas oning related to prognos is .
P re d ic tive re a s oning Ethic a l re a s oning Reas oning related to ethical is s ues that emerge in practice. Pro es s ional s tandards o practice and duty o care are embedded in decis ion making about the individual’s health care needs .
• Differentiation strategies which identify • • • •
structures at fault or mechanisms of symptom production (pain mechanisms). Brief appraisal of structures which could be contributing or are considered not to be at fault. Con rmation of impairment with speci c manual tests. Risk assessment of vulnerable structures where treatment may be harmful. Manipulative or movement therapy treatment techniques which effect, within session, change in quality or quantity in movement or which 27
C H AP TE R 1
The Maitland Co nc e pt as a c linic al prac tic e rame wo rk
address contributing factors which mediate symptoms. • Treatment technique where design can be directly traced back to and link with functional limitations or participation restrictions. • Treatment techniques which are designed around what, for the patient, would be a successful outcome of treatment. In effect, examination should be appropriate to the patient’s individual needs and tolerances (patient-centred), should be safe (planned collaboratively and with consent) and should ensure effectiveness of treatment within scope of practice. As with the subjective examination the physiotherapist should have the capacity to be exible in physical examination to ensure that every aspect of it is relevant to the patient’s condition and presentation. This needs some thinking about sometimes, but more often than not the patient will tell you what to do!
Inte rve ntio ns It is important to clarify that there are no and never have been ‘Maitland techniques’. Techniques of manual therapy, mobilization and manipulation should not be attached to any one concept of practice. The most important feature of any treatment using manipulative physiotherapy is that it achieves its known desired effects for the individual patient. It is important, therefore, to have:
Patient problems in relation to movement impairment or de cit will usually present as painful movement, movement which is protected, movement which is restricted, movement which is excessive or movement which is sensitive. Fear, anxiety and loss of trust in movement should always be considered. Manipulative physiotherapy techniques, therefore, should be designed around dealing with these patient problems using mobilization or manipulation techniques which reduce movement-related pain and excessive protection (e.g. grade I and II accessory or physiological movements) and which reduce restrictions in movement (e.g. grade III and IV physiological and accessory stretching ). The techniques should also be designed around dealing with movement sensitivity (e.g. neurodynamic sliders and tensioners) and, at the same time, addressing cognitive or other psychosocial mediators of the patient experience. At all times individual therapeutic interventions should be placed in the context of an outcome of healthy productive living. Therefore, linking treatment techniques to functionally demonstrated activity limitations and even performing the technique in the functionally limited movement will open up an extensive range of treatment possibilities. An example of this is the reduction in pain and increased movement capacity when a lateral glide of a patient’s tibia is applied during active knee exion and extension after arthroscopic debridement of meniscus fragments (Fig. 1.5).
• An overview of mobilization and manipulation and their effects • An understanding of how techniques are selected, progressed and related to selfmanagement strategies.
An overview o mobilization and manipulation and their e ects The technique should be adapted to the patient’s needs rather than the patient’s problems being made to t a particular approach. As a general theme, manipulative physiotherapy ts into the domain of movement therapies. The effects of manual therapy are at all levels of the movement continuum (see Fig 1.14) (Cott et al. 1995). The real effects will go beyond the tissues and have mechanical, physiological and behavioural effects all along the movement continuum. 28
Fig ure 1.5 • Lateral tibiofemoral movements.
In te rve n tio n s
The key to well-reasoned selection of manipulative and movement therapy interventions are to:
• Know the movement which reproduces the • •
•
Fig ure 1.6 • Superior radioulnar joint: posteroanterior movement in supination.
• Another example is the patient with lateral epicondylalgia who has pain around the lateral epicondyle of the elbow when gripping. The pain-free grip strength is improved when a posteroanterior glide is applied to the head of the radius (Fig. 1.6). A further example is the patient with symptoms of nerve entrapment in the upper extremity associated with posterior shoulder tightness and restricted upper limb neurodynamic test-median nerve bias. The nerve entrapment symptoms and upper limb neurodynamic range improves when an anteroposterior glide is applied to the humeral head (Fig 1.7).
•
•
• •
• Fig ure 1.7 • Anteroposterior movement: in abduction.
patient symptoms. Know what those symptoms are (pain, stiffness, spasm, giving way, weakness, etc.). Know what effects manipulative and movement therapy techniques have been shown to have on pain, stiffness, spasm, weakness and other symptoms. Know all possible techniques or interventions associated with the movement impairment (accessory and physiological movement, functional corners, neurodynamic sliders and tensioners, motor control activation and recruitment). Know how to deal with issues which affect the patient’s experience and responses to movement (behavioural issues – avoidance, cognitive issues – fear of movement). Decide on the technique or intervention most likely to produce the desired effect (pain relief, reduce stiffness, reduce protective spasm, reduce nerve mechanosensitivity, improve motor control, activation and recruitment, reduce avoidance and fear of movement, improve functional capacity and performance of activities). Calibrate the technique parameters to suit the presenting severity and irritability of the symptoms and the stage in the pathological natural history of the disorder (starting position, localization and application of manual technique). Perform the technique or intervention and reassess its immediate effects. Plan further use of the intervention and associated techniques including progression and integration of treatment to different presenting impairments. (For example, cervical lateral glide with the median nerve in progressive positions of lengthening; stretching of the shoulder joint capsule to facilitate rotator cuff muscle re-education; mobilization of a stiff ankle to enhance alignment correction and reduce anterior knee pain). Work towards a shared successful outcome whereby changes are made to interventions and management strategies dependent upon responses to treatment. 29
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An unders tanding o how techniques are s elected, progres s ed and related to s el -management s trategies
• Thoughtful relationships between the treatment
It is clear, therefore, that the selection and progression of manipulative and movement-related therapies no longer adheres to well-established formulas. Maitland’s order of ef cacy (Maitland 1992) or clinical groupings (H engeveld & Banks 2005) (Fig. 1.8) serve to give very loose selection criteria. Well-designed research methods have given the manipulative therapist a wider and more critical overview of selection of interventions and how we need to think of combinations of therapies which have been shown to have the best effects (Maricar et al. 2009). Moore and Jull (2010), in an editorial, suggest that multimodal packages of treatment are now being utilized in most situations. These packages should include a passive/ active intervention which supports functionally relevant exercise, education and advice. The key strategies for the selection of manipulative therapy interventions now lie in clinical reasoning underpinned by a broad and deep knowledge of manipulative and movement therapy theory and a broad and deep range of sensitive and speci c handling skills. The key drivers for selection are:
• Collaboration with the patient so that interventions are well explained and meaningful to the patient. • Well-established and shared outcomes of interventions which are known to be safe and effective. • Support from research evidence. • A deep understanding of the responses of NMS tissues and the patient to injury, surgery, disease or disorder.
and functional de cit. • An attention to detail in the skilled application of techniques underpinned by knowledge of structure and function and an understanding of pain (symptom) mechanisms. • An awareness of cognitive and behavioural issues which may impact on responses to interventions or contribute to mediating their effectiveness. Table 1.3 shows examples of selection, progression and functional integration of manipulative and movement therapy interventions based on clinical reasoning hypothesis categories (Jones et al. 2006a). In this case the selection, progression and functional integration relate to a patient who has suffered an ankle sprain (two months ago) and is primarily experiencing ankle pain and stiffness.
As s e s s me nt Assessment refers to:
• Analytical assessment at a rst consultation • • • • •
(examination and treatment planning). Pretreatment assessment (the effects of the previous treatment session). Assessment during every treatment session (the ef cacy of a technique at a particular stage in treatment). Progressive assessment (comparing the effects of treatment over three or four sessions). Retrospective assessment (looking back and re-evaluating treatment when progress has stopped or slowed). Final analytical assessment (the nal outcome of treatment) (Maitland 1987).
As s es s ment and outcome meas ures
Groups
Pain (group 1)
Stiffness and pain (group 3)
Pain and stiffness (group 3a)
Stiffness (group 2)
Stiffness and pain (group 3b)
Fig ure 1.8 • Subdivision of patient groupings. 30
The evaluation of what would be a successful outcome of treatment, including mobilization and movement therapies, begins as soon as the patient identi es what, as far as they are concerned, is the main problem. Any outcome should be measurable whether qualitatively or quantitatively. O utcomes should be based on sound clinical reasoning and individual to the patient’s needs.
As s e s s m e n t
Table 1.3 Examples of selection and progression of treatment
Hypothesis category and supporting evidence
Reasoning and selection
The patie nt’s o wn pe rc e ptio ns and e xpe rie nc e s : the patient believes there is something out o place in his ankle. He believes that his ankle joint is being worn away because o this. As a result o these belie s he has developed a limp and does not put weight on his ankle because it hurts him to do so. So urc e /impairme nt: the patient complains o a deep ache across the ront o the ankle, anterior knee pain and tiredness o the whole limb associated with aching back muscles.
Examination reveals that the ankle is pain ul and sti to move and more so when the talocrural joint sur aces are compressed together and moved … SELECTION: it is very important at the outset o treatment to educate and in orm the patient about his pain perceptions and belie s. Understanding pain mechanisms will help the patient to change his belie s about pain and harm. Use o an X-ray to dispel his ears would also be use ul. Mobilization techniques such as graded exposure to movement can then be employed more e ectively. Start with accessory grade III mobilization techniques o the talus with the talus distraction to treat the joint pain and sti ness. Progress onto the same techniques without distraction, then with compression and then in the unctional load-bearing position as pain and sti ness are reduced and unction improves. (Collins et al. 2004) Symptom areas suggest a sti ankle joint (talocrural or in erior tibiof bular) leading to alignment aults in the knee (patello emoral or tibio emoral) and impacting on underlying postural aults within the lumbar or thoracic spine (Prior 1999). SELECTION: the ankle needs mobilizing, alignment aults need addressing, spinal adaptation needs investigation.
Dys unc tio n (ac tivity, partic ipatio n): symptoms mani est a ter a period (two hours) o prolonged walking, the ankle always eels sti a ter an ankle sprain two years ago, the knee and back symptoms came on gradually over the last six months leading to progressive discom ort with walking. Not so good at bowling at cricket now because symptoms a ect per ormance. Pain me c hanis ms : as the ankle gradually gets tighter and locally pain ul with walking, local nociceptive mechanisms in the ankle and knee would be suspected due to overload o the sensitized talocrural and tibio emoral or patello emoral tissues. The backache is likely to be originating rom the muscles themselves with adaptive activity and the whole leg tiredness could be associated with a disproportionate autonomic nervous system response to irritation o postganglionic sympathetic chains in the postural adapted thoracic spine. Always keep in mind vascular or neurogenic claudication or the leg symptoms, as well as aches and pains as part o ongoing medical conditions such as diabetes or metabolic def ciencies.
Ankle sti ness is a key issue and could also be the cause o the source o anterior knee pain. One possibility to explain symptoms is sympathetic mediated tired eeling o the whole lower limbs associated with sti ness in the thoracic spine (Cleland & McRae 2002). SELECTION: a mobilization or mobilization with movement technique which addresses ankle sti ness and nociceptive mechanisms (e.g. a grade III or IVanteroposterior mobilization o the talus with active dorsi exion in standing). The patient can still play cricket, there ore the severity and irritability o symptoms is not too high and a lot o walking is needed or the symptoms to become noticeable (Fryer et al. 2002). The local pain rom an overloaded knee should settle with treatment o the ankle and correction o adaptive changes at the knee and spine. Sympathetic mediated symptoms can be a ected by manipulative techniques to the thoracic spine i these symptoms are due to mechanical irritation o the postganglion sympathetic chains (Cleland et al. 2002).
Co ntributing ac to rs : there would be an important need to address correction o alignment aults at the the knee and postural adaptations in the thoracic spine. These may mani est as motor control and recruitment issues around the hip, pelvis and trunk or mobility problems within the thoracic spine.
SELECTION: motor control and movement corrections with exercise and mobilization o the thoracic spine. It is important to use reassessment o each o these potential interventions to establish their contribution to the patient’s symptoms and signs.
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Table 1.3 Examples of selection and progression of treatment—cont’d
Hypothesis category and supporting evidence
Reasoning and selection
Patho bio lo g y: as the ankle has been sprained, f brous repair within the ankle collateral ligaments will have taken place. There may be possible signs o articular cartilage attrition at the knee. Postural adaptation inducing degenerative changes within the thoracic acet joints may be one explanation or the sympathetically mediated limb symptoms.
SELECTION: through range (grade III) and end o range (grade IV) ankle and thoracic mobilization techniques. Possible need to use through range mobilization o the knee to e ect pain relie related to joint sur ace irritation. Through range accessory mobilization o the thoracic intervertebral joints and ribs i pain and sti ness o the thoracic spine is associated with limb symptoms.
Ps yc ho s o c ial me diato rs : mediators o recovery could take the orm o worry about reduced unction because o pain and stress related to concern over what is wrong. Ongoing worry about reliance on medication and impact on unctional capabilities and ear o need or surgery may also be a actor. The psychological impact o the ankle sprain should also be linked to the patient’s perceptions and pain belie s as detailed above.
SELECTION: integrate manipulative and movement therapy techniques with an attention to in orming, reassuring and supporting psychological and social concerns.
Tre atme nt: there is clear evidence o a need or movement therapies and behavioural approaches.
SELECTION: whilst in standing with dorsi exion o the ankle, mobilize the talus rom anterior to posterior. E ect correction o alignment and motor control at the knee and trunk/pelvis. In long sitting slump mobilize the sti ribs associated with the sympathetic type symptoms in the limb. Integrate unctional gains into daily activities (walking) and recreation (cricket).
Pro g no s is : a success ul outcome is based on collaborative goals to ensure the patient has the capacity to per orm activities without pain and discom ort.
SELECTION: gradual reconditioning o tissues to as ull a capacity as is possible. For impairments: ull range o ankle and thoracic mobility, corrected alignments and adaptations o the knee and spine. For activities: recondition both physically and mentally to enable unhindered per ormance o activities such as walking and ast bowling. For healthy living: enable a return to unctional status to enhance healthy living and eeling o wellbeing.
O utcome measures should be evidenced throughout the examination and assessment process and form the means by which interventions are evaluated in a meaningful and informative way. Darzi (2008) advocates that outcomes of interventions should be patient-centred (informed choices), safe (free from risk) and effective (achieve their desired effects. Evaluation or analytical assessment of treatment has always been the keystone of the Maitland Concept. Continual assessment forms the basis of decision making, justi cation for treatment and progression to discharge. 32
Individual outcome measures or asterisks (the most important clinical features for reassessment) can be utilized from anywhere within the clinical process. C/ O parameters are:
• The area and nature of the patient’s symptoms as documented on a body chart. • The amount of de cit in everyday activities or occupational or recreational participation. • Evaluation of severity or irritability. • The number of recurrences over a given period of time.
As s e s s m e n t
• Volume of medication needed to effect pain
(Physio)therapy process
relief. P/ E parameters are:
• O bservable impairments. • Ability to carry out functional activities relevant • • • • •
to symptom reproduction. Active movements (range/ pain/ response and quality of movement). Passive movements (movement diagrams). Isometric testing, recruitment and muscle strength or length. Nerve conduction and neurodynamic capacity. Impact on psychosocial factors.
These individual outcome measures can be linked to speci c and utility outcome instruments (usually questionnaires) which have been validated, for example, SF-36 (Brazier et al. 1992), to enhance and support selection of treatment, progression and decisions to stop treatment. Within the Maitland Concept, analytical assessment means looking at the bigger picture, re ecting on practice and carrying out what is, in effect, an internal moderation of action taken. Assessment means evaluation. Every action, treatment, exercise or management strategy should be evaluated to ensure its patient-centred desired effect, its safety and its measured impact on the patient and their health and well-being.
Analytical as s es s ment • Analytical assessment is the keystone of this • •
•
•
concept of manipulative physiotherapy. Analytical assessment (evaluation) includes observation, judgement and re ection. It encompasses all procedures which are undertaken to monitor the therapeutic process between the patient and the physiotherapist. It serves to assess the indication for and effectiveness of therapeutic intervention in all treatment sessions. Assessment and treatment procedures are directly linked to each other, as many examination techniques can be used as treatment strategies as well (Fig. 1.9). Various forms of assessment are being employed during the therapeutic process.
Session 1
Last session
Assessment
Treatment Welcome info
Parting phase Therapeutic relationship
Fig ure 1.9 • Assessment serves to monitor the overall therapeutic process between the physiotherapist and the patient.
• Assessment procedures are a core skill in the planning and execution of physiotherapeutic interventions. • The therapist decides to treat patients only after a thorough assessment and to monitor the effects of the treatments during every session. • Analytical assessment encompasses the overall physiotherapeutic process, in which various forms of assessment are being employed, with the use of examination and treatment skills. Figure 1.10 depicts the relative importance of analytical assessment. In the process of analytical assessment, the physiotherapist should consider the following questions and aims:
• Is the problem of this patient suitable for manipulative physiotherapy? This relates to questions of: ○ indications ○ precautions Analytical assessment Assessment forms (initial, reassessments, assessment while treating, retrospective, final analytical)
Examination skills
Treatment skills, including manual techniques
Fig ure 1.10 • Analytical assessment. 33
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○ contraindications ○ screening for biomedical disease, including
consideration of red ags ○ previous treatments the patient received for the same problem. • If the problem of the patient does not seem suitable to treatment, the question arises to whom the patient should be referred? The therapist, therefore, needs to develop a network of various clinicians to whom the patient could be referred.
• If the patient’s problem is suitable for further treatment, consider how treatment should be approached and how should the therapeutic process be monitored? This relates to questions of: ○ physiotherapy diagnosis ○ de nition of short-term and long-term goals of treatment (expressed in terms of the International Classi cation of Functions, Disability and H ealth – ICF) (WH O 2001) ○ selection of treatment methods and techniques ○ selection of parameters to monitor effectiveness of the selected treatment interventions ○ how to progress carefully and adapt the selected treatment, if positive results are being achieved ○ decisions when to integrate other treatment forms and techniques ○ decisions when to interrupt or stop the treatment • Consider active integration of the patient in the therapeutic process – development of a therapeutic relationship with aspects of:
○ motivation ○ trust and con dence ○ information at regular moments of the ○ ○ ○
therapeutic process education and learning theories – adapting information strategies to the cognitive level of the patient monitoring the information to ensure it deepens the understanding of the patient or seems to confuse them cognitive–behavioural therapy: how can a person be motivated to change behaviour? This includes recognizing phases of change related to motivation which an individual
34
may go through before new (movement) behaviour becomes an automatic part of daily life functions.
Forms o as s es s ment In order to be able to monitor the overall therapeutic process from the rst to the last encounter, various forms of assessment are described in this concept of manipulative or musculoskeletal physiotherapy:
• Initial assessment • Reassessment procedures • Assessment while performing a treatment-techniques • Retrospective and prospective assessment • Final analytical assessment. O ne suggestion is to employ the various forms in so-called ‘critical phases’ of the therapeutic process as they aid in re ection and clinical decision making (Fig. 1.11).
Firs t a s s e s s me nt The rst session(s) serve to gather information with regards to causes, contributing factors, precautions, contraindications, treatment planning and the development of a therapeutic relationship (Fig. 1.12). The main objectives of initial assessment procedures, consisting of interview and test procedures, can be summarized as follows:
• De nition of the patient’s problem from the speci c perspective of a physiotherapist: physiotherapy diagnosis, mostly expressed in terms of movement dysfunctions with the aid of the terms of the International Classi cation of Functioning, Disability and H ealth – ICF (WH O 2001) (i.e. structure and function – impairments; activities – limitations and resources; participation – restrictions and resources). • H ypotheses generation with regards to: ○ sources of dysfunction ○ movement components and structures ○ contributing factors to the cause and/ or maintenance of the disorder ○ pathobiological processes (tissue processes with regards to pathology, stages of healing; neurophysiological pain mechanisms: nociceptive, peripheral neurogenic, CNS modulation, ANS as output mechanisms)
As s e s s m e n t
Retrospective assessments Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9
Initial assessment (including initial RX) Reassessments
Final analytical assessment
Reassessments
Reassessments
Reassessments
Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9
Assessment during application of a technique
Assessment during application of a technique
Assessment during application of a technique
Assessment during application of a technique
Fig ure 1.11 • Forms of assessment – employed in various stages of the therapy process.
○ contraindications and precautions to
• De nition of treatment objectives and selection
examination and treatment procedures ○ individual illness experience (regarding expectations, thoughts, feelings, level of understanding and attitude of the patient relating to the problem, in uence on/ of social environment, particular needs of the patient) ○ management: treatment objectives, selection of treatment procedures, progression of treatment ○ prognosis (short term and long term prognosis). • De ning subjective and functional parameters (asterisks) to monitor the progress and success of treatment.
of initial treatment methods.
The f rs t s e s s ion The course of a rst session usually will follow various stages (Box 1.11): 1. Introduction phase. 2. Subjective examination – interview of the patient. 3. Planning of the physical examination (Box 1.12). 4. Physical examination (Box 1.13). 5. Initial (probationary) treatment. 6. Planning of the next session (Box 1.14).
Causes Contributing factors
Treatment goals Selection of interventions
CLINICAL JUDGEMENT
Contraindications? Precautions?
Active integration of the patient in the therapeutic process (Therapeutic relationship – communication)
Fig ure 1.12 • Various objectives of assessment in the initial phase of physiotherapy. 35
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Box 1.11 First examination and treatment • • • •
Subjective examination (C/O – ‘complains o ’)* Name, date o birth, pro es s ion, hobbies , medical diagnos is , goals o patient Main problem, including s hort s tatement on level o dis ability in daily li e Body chart
• • •
Behaviour o s ymptoms (over 24 hours /s even days ) His tory (Hx), pres ent and pas t his tory Medical s creening ques tions The s equence o ques tioning may be varied, according to the s pecif c problem o the patient.
Main problem
Body chart
24h behaviour
It may be dif cult for a patient to understand that each member in a multidisciplinary team follows a unique frame of reference, which is in a sense exclusive to their profession (Kleinmann 1988). Therefore it is essential to inform the patient about the speci c role of physiotherapist in the diagnosis and treatment of movement dysfunctions, being complementary to medical diagnosis and with a focus on restoring healthy living. This information needs to be given in an early phase of the encounter, before embarking on the examination and treatment process.
History (Hx)
Screening questions
Furthermore, explanations need to be given about the setting and the steps which will be followed in the rst session (interview, physical examination and movement testing, rst probationary treatment, reassessment). It may be necessary to explain that this examination is highly important to individualize the treatment to the speci c problem and needs of the patient. Additionally, it is necessary to nd out if the patients have been expecting physiotherapy as a treatment option for their problem at all
Box 1.12 Planning a physical examination This es s ential phas e be ore per orming a phys ical examination includes three s tages : •
Re ection on the previous phas e o the s ubjective examination: have I s earched or all in ormation with regards to pos s ible contraindications and precautions to examination- and treatment procedures ? • Cons ideration o s ome hypothes es (‘Making implicit hypothes es explicit’) Sources o s ymptoms Contributing actors Pathobiological proces s es Tis s ue pathology Phas es o tis s ue healing Dominant neurophys iological pain mechanis ms (nociceptive, peripheral neurogenic, CNS modulation,
36
Autonomic NS output mechanis ms ) Contraindications to phys ical examination procedures Precautions to phys ical examination procedures – determined by actors o s e ve rity, irritability and nature o the dis order. • Extent o examination procedures : • • •
•
Which s ymptoms do I want to reproduce? Which s ymptoms do I want to avoid reproducing? Extent o tes ting: until f rs t ons et o pain (P 1 )/to the limit o the movement (to L, res pecting pain) • Initial tes ts /s tandard tes ting/s tandard tes ting with overpres s ure/‘i neces s ary’ tes ting Sequence o the phys ical examination, including an es timation o f rs t exploratory treatments as well as planning o reas s es s ment procedures .
As s e s s m e n t
Box 1.13 Physical examination (P/E), including reassessment Phys ical examination procedures encompas s various movement tes ts , s pecif c s creening tes ts or biomedical dis eas e, probationary treatment procedures and reas s es s ment as below: •
• • •
•
• •
Obs ervation • General obs ervation o pos ture, bodily alignment • Local obs ervation o pos ition, was ting, s wellingWillingnes s to move the s tructure • Pres ent pain? (PP) • Correction o obs ervable as ymmetries Functional demons tration – unctional tes ts , including di erentiation procedures i pos s ible Brie apprais al (cons idering plan o examination – continue or change plan? ) Active tes ts (obs erving quality, quantity and s ymptom reaction) • Gait analys is • Active phys iological movements (o main movement component; may include movements o other components in the plan: joint re erring in the area; joints above and below area o s ymptoms ) ‘I neces s ary’ tes ting to active tes ts including: • Overpres s ure • Tes t movements per ormed as ter, repeated, s us tained, per ormed under load. • Combined movements • Compres s ion, dis traction, tapping tes ts Brie apprais al (cons idering plan o examination – continue or change plan? ) Special tes ts (neurological conduction – radicular or peripheral nerve dis tribution; ins tability tes ting,
vas cular tes ting, other tes t procedures as as pect o s creening or biomedical dis eas e) • Neurodynamic tes ting (may be per ormed as part o pas s ive tes ting and component analys is ) • Pas s ive tes ting (as component analys is , including regular reas s es s ment) • Movement diagram (s ee page 58) • Acces s ory movements (def ne pos ition in phys iological range: in … do …) • Phys iological movements (e.g. F/Add hip, Shoulder quadrant; PPIVMs ) • Mus cle length tes ts • Palpation • Temperature, s welling, was ting, s ens ation, pos ition o s tructures , tendernes s o s tructures • So t tis s ue examination (e.g. ligaments , mus cle, tendon) • Nerve palpation (Palpation o temperature/s welling may be done during obs ervation and regularly during P/E; palpation o tis s ue tendernes s /pos itions may be per ormed be ore pas s ive tes ting.) • • • • •
Check cas e reports and radiographs Highlight m ain ndings with asterisks (to allow or quick re erral in later s es s ions ) Plan reas s es s ments (when, which in ormation, which tes ts (includes s ubjective s tatement and P/E tes ts ) Firs t probationary treatment, including reas s es s ment Warning, ins tructions and recommendations . (Patient is encouraged not only to obs erve but als o to compare.) To be included in patient records .
Box 1.14 Planning of the following session(s) Subs equent s es s ions mus t be planned thoroughly to make s ure that examination procedures are properly completed and als o to adapt and ref ne the initial treatment procedures . Planning s teps or s ubs equent s es s ions s hould encompas s :
•
•
•
• •
Subjective reas s es s ment: s eeking s pontaneous in ormation and comparis on o activities and s ymptoms Additional s ubjective examination ques tions not completed at the f rs t cons ultation Reas s es s ment o the phys ical examination parameter, which reproduced the patient’s s ymptoms in the previous s es s ion as well as thos e parameters which have been cons idered relevant ‘comparable s igns ’
•
•
•
Additional examination procedures , s uch as , or example, neurological conduction tes ting, ins tability tes ting, not completed at the f rs t cons ultation Screening o other movement components involved (active tes ting, pas s ive tes ting) ollowed by reas s es s ment procedures Reas oning about treatment – what kind o treatment will be per ormed i the patient is better/the s ame or wors e as a res ult o the previous s es s ion(s )? How are the treatment techniques bas ed on the examination f ndings and available res earch evidence? What kind o s el -management s trategies will be incorporated into the treatment – how will this taught to the patient? How will it be reas s es s ed?
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(particularly in those cases where a patient has been referred by another medical practitioner). Also, it is useful to ascertain whether the patient understands that physiotherapy encompasses various methods of movement therapy (not only gymnastics), such as touching as used in, for example, passive mobilizations, manipulations, soft tissue techniques and other modalities. In this introductory phase, by means of careful listening and observing, the therapist may become aware of some anxieties of the patient with regards to therapy, setting and therapist, which may be addressed as well (Main & Spanswick 2000).
Phys ical examination • • •
•
• •
Dis cus s with the patient es s ential s teps , or example, reas s es s ment procedures . Gain cons ent or touching, particularly i the patient is not able to s ee the phys iotherapis t. Explain to the patient that the active tes ts which reproduce the s ymptoms will be us ed to compare treatment res ults at a later s tage. As k the patient to try to remember how the movement elt and which s ymptoms occurred. When per orming acces s ory movements on the s pine, explain to the patient that es pecially thos e movements which provoke the pain may be us ed in treatment s trategies but per ormed s hort o the ons et o pain or with a controlled amount o pain. I there are avourable res ults in reas s es s ment procedures , s ummarize the res ults or the patient. Be mind ul o what is being s aid to the patient as it may be di erently perceived by the patient i a therapis t s ays ‘I cannot f nd anything’ in contras t to ‘I think your re exes , mus cles s trength are per ectly in order’.
Re a s s e s s me nt b e ore a nd a te r tre a tme nt
• At the beginning of each subsequent treatment session, pretreatment assessment to re ect on the reactions to the last treatment and the time leading up to the current therapy session. • Immediately after the application of the various treatment interventions – proving the value of the intervention and monitoring if treatment objectives step by step are being achieved. These interventions may include passive mobilization techniques, active movements, and application of physical agents, information and educational strategies. • At the end of the treatment session. Purpose of reassessment procedures:
• Allows the physiotherapist to compare •
•
•
The effects of the various examination and treatment interventions are continuously monitored by reassessment procedures and the treatment is adapted to the actual situation of the patient as required. Reassessment procedures should take place during each treatment session:
• During the initial physical examination phase in the rst encounter, after the examination of various active and passive movement tests, before continuing to examine another possible movement component involved. 38
•
treatment results and prove the value of selected interventions. Provides differential diagnosis: not only examination ndings, but also reactions to treatment interventions make a contribution to differential diagnosis of the sources and contributing factors of movement dysfunctions (‘differentiation by treatment’). Enables the physiotherapist to re ect on the decisions made during the diagnostic and therapeutic processes. Through reassessment procedures, hypotheses with regard to sources, contributing factors and management may be con rmed, modi ed or rejected. The therapist learns to recognize patterns of clinical presentations, which will aid in future decision making. Reassessment procedures support the development of the individual, experiential knowledge base of the physiotherapist, and thus play a central role in the development of clinical expertise. Enables the patients in their learning processes. From a cognitive–behavioural perspective, reassessment procedures play a central role in the development of the perception that indeed bene cial changes occur, even if the pain still seems to be lasting. If patients are being guided towards the experience of the various changes in the test movement (e.g. quantity, quality of the movement, along with symptom responses), they may learn to perceive changes which they initially did not expect to occur. Reassessment procedures are one of the crucial aspects of the therapeutic process.
As s e s s m e n t
Indicators of change It is essential to bear in mind how symptoms and signs may change in order to guide the patient comprehensively in reassessment procedures and to monitor even minor bene cial changes (Box 1.15). H owever, it is essential that the starting point is clear: if it is not suf ciently clear from the rst assessment which daily life functions are limited due to pain or other reasons, comparison to identify change in later sessions is compromized. This may often leave the patient in doubt as to whether the therapy has really served its purpose. Furthermore, the de nition of clear treatment objectives may be impeded and neither patient nor physiotherapist is capable of observing in suf cient detail if something is changing bene cially in the patient’s situation.
Box 1.15 Indicators of change Sub je c tive e xa mina tion •
• • • • • • •
Pain: s ens ory as pects s uch as intens ity o pain (may be expres s ed in VAS), quality o s ymptom, duration, localization, requency Emotions /mood Normalization o level o activity and participation Conf dence in us e o body during daily li e s ituations Motivation/s el -e f cacy Decreas e in us e o medication Increas ed unders tanding Deliberate employment o coping s trategies i dis com ort increas es again
P hys ic a l e xa mina tion
Balanced reas s es s ment o s ubjective and phys ical parameters Note: a balanced approach to reas s es s ment o s ubjective and phys ical parameters is neces s ary. Some phys iotherapis ts ocus s olely on the obs ervation o phys ical examination f ndings and may only employ tes ts with an acceptable intertes ter and intrates ter reliability. However, it is argued that a certain degree o s cepticis m s hould be retained i tes ts with a high reliability coe f cient are directly claimed to be clinically us e ul and vice vers a: that tes ts with a relatively low coe f cient would not be us e ul clinically (Keating and Mayas 1998, Bruton et al. 2000). O ten the combination o tes ts o both s ubjective and movement parameters may provide the clinician with valid reas s es s ment parameters (Ches worth et al. 1998). Leaving out a s ubjective parameter carries the inherent danger that the therapeutic proces s becomes a rather mechanical proces s in which not much s pace is le t or the individual perceptions o the patient with regard to the dis order. Furthermore, the obs ervation o the more s ubtle behavioural parameter (e.g. les s guarding o the a ected arm), changes in acial expres s ion and us e o words may be indicative that changes in the individual illnes s experience are taking place.
The ‘art’ of reassessment • With reassessment procedures it is essential that the physiotherapist develops a clear image as to which interventions have an effect on the patient’s condition. Some interventions may
• • •
• • •
Ins pection parameter (pos ture, orm, s kin, aids ) Active tes ting: range o movement, quality o movement, s ymptom-reaction Pas s ive tes ting (as neurodynamic tes ting, PAIVMs , PPIVMs , mus cle length): change in behaviour o pain, s ens e o res is tance and motor res pons es Mus cle tes ting: changes in s trength, quality o contraction and s ymptom res pons e Palpation f ndings : quality and s ymptom res pons e Neurological conduction tes ting changes in quantity and quality o the res pons es
Tre a tme nt inte ns ity •
Higher intens ity o active movements , pas s ive mobilizations (grade, duration, inclination, combinations ), exercis es , s o t tis s ue techniques without provoking dis com ort
Be ha vioura l p a ra me te r •
As , or example, acial expres s ion, non-verbal language, eye contact, us e o key words and key ges tures , habitual integration o extremity with daily li e unctions
in uence some active parameters, while other interventions in uence other tests and activities. • Consequently, it is necessary to follow multiple parameters in reassessment procedures. • Profound reassessment: the indicators of changes have to be monitored meticulously rather than being satis ed with a more super cial question at the beginning of a session as for example ‘how have you been?’ without further follow-up of the information. 39
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• A balanced approach to reassessment and treatment procedures: if some patients have a condition with a high level of irritability, or have dif culties getting up and down a plinth, it may be useful to reassess only the subjective experience regularly and to perform some reassessment test while the patient is still lying on the treatment plinth. • Cognitive objectives: in case of educational treatment strategies, monitor if the information has been understood and acted upon. This engagement should manifest as changes in daily living activities and exercise compliance. The clinician should also re-evaluate the patient’s beliefs and whether these have also changed. For example, does the patient still believe that any pain is harmful. • In some cases, where pain seems to have become a dominant feature in the individual illness experience without any changes over time, it may be useful to nd metaphors for the experience of the patient (e.g. a wave on the ocean, which may be subsiding). In other cases it may be helpful to integrate more functional movements as, for example, ‘tennis service’ or a working activity – in which the patient learns to observe various parameters other than pain alone as a sensation. • It is essential that the physiotherapist remains in control of the treatment collaboratively with the patient. G iven practice and experience, treatment, including profound reassessment procedures, is not a lengthy procedure.
As s e s s me nt while p e r orming a tre a tme nt p roc e d ure Assessment during the application of treatment procedures need to be distinguished from reassessment procedures.
As s es s ment during the application o treatment Note: while per orming a pas s ive movement, exercis es , educational s es s ion or other therapeutic procedures with a patient, the phys iotherapis t has to purs ue the ollowing ques tions : • Are the objectives o the treatment procedure being achieved? • Is the treatment ree rom undes irable s ide e ects ?
40
Particularly during the application of passive mobilizations, changes in the behaviour of pain and sense of tissue resistance should be monitored. If pain or the feel of resistance changes, immediate adaptation of the techniques will then be possible. As long as these changes are favourable, the technique may be continued. Also, when the changes cease to take place after a period of treatment, it is often useful to perform a reassessment-procedure of the main parameters of physical examinations to evaluate the direct effect of the technique applied. Therefore, assessment while applying a treatment technique is a decisive factor in determining the duration of the technique being performed. O n the other hand, the physiotherapist needs to consider possible undesired side effects. In some cases, while monitoring the desired results of a therapeutic intervention, simultaneously the physiotherapist may need to observe the following aspects by noting any adverse or undesirable responses to treatment such as: • In ammatory signs (alertness to swelling, redness, temperature). • Increase of pain (particularly in cases of acute, irritable nociceptive and peripheral neurogenic pain states). • Neural conductivity (monitoring re exes, muscle function, sensation). • Impaired healing processes in soft tissues or bones (in relation to the phases of physiological healing processes). • Autonomic reactions, for example, redness of skin, sweating, coldness (e.g. during palpation of the spine). • G eneral tension with increased muscle guarding and breathing patterns (particularly in those patients, whose contributing factor to their disorder may be lack of relaxation or autonomic imbalances). • Self-ef cacy beliefs/ externalization of locus of control/ development of passive coping strategies (in cases where the patient seems to attribute the effects of treatment only to the hands of the therapist, without applying the suggested self-management strategies). • Fear of movement (e.g. increase in fear-avoidance behaviour). • Confusion (e.g. in educational sessions, where much information is given without reassessment and consideration of the cognitive level, previous knowledge and beliefs of the patient).
As s e s s m e n t
Re tros p e c tive a s s e s s me nt
When improvement has stopped
O ne of the most essential, but often neglected, forms of reassessment is retrospective assessment in combination with skilled communication (Maitland 1986). Retrospective assessment should take place at regular intervals in the overall process, in which the physiotherapist re ects on all the decisions and hypotheses made so far and patients are encouraged to compare changes in their condition over a longer time period rather than session-to-session changes. See Box 1.16 for reassessment questions.
Retrospective assessment is also useful if therapy seems to be stagnating or does not seem to bring the desired results. The following re ections need to be considered:
Box 1.16 Retrospective assessment
• H ave I compared the subjective and physical • • •
Ques tions need to be as ked to es tablis h the ollowing: • •
•
• • •
•
• •
• •
•
As s es s ment o the overall well-being o the patient in comparis on with the f rs t s es s ions Which s ubjective and phys ical parameters (as teris ks ) have improved s o ar? Which ones have remained unchanged? The percentage improvement o C/O and P/E as teris ks . Which as pects o the as teris ks have and have not changed? Which treatments have helped the mos t? Are agreed treatment goals being achieved? What has the patient learned s o ar? What was es pecially important to the patient in the learning proces s ? Monitoring the e ects o the various treatment interventions (patient’s in ormation as well as checking o treatment records ) What does the patient eel is needed to change the remaining s ymptoms and s igns ? Pro s pe c tive as s e s s me nt: (re)determination o the treatment objectives or the next period o therapy: does the therapy need to be adapted to newly def ned goals ? (‘Which aspects should we work together on now?’) It may be us e ul to ‘think rom the end’: which treatment objectives s hould be ollowed in order to optimize the ‘individual s ens e o well-being’ with regard to activities in daily li e? Determination i other therapeutic or medical meas ures may be neces s ary Does the therapis t need to undertake more compliance enhancement s trategies in order to s upport the patient in the behavioural change with regard to s ugges tion, exercis es and recommendation? (Re)determination o the parameters to monitor the agreed goals o treatment. (It may become a more unctional movement parameter, s uch as , or example, tennis s ervice, bending activities as per ormed at work)
• • •
•
parameters (asterisks) regularly enough and in suf cient detail? Did I ensure that the patient would become aware of positive changes in these parameters as well? Did I follow up the correct physical ‘asterisks’, which re ect the patient’s main problem and the goal of the therapeutic intervention? H ave I performed a review of the therapeutic process collaboratively with the patient? H as the right source of symptoms been treated? H ave potential contributing factors been addressed adequately (physical, psychological, environmental)? H ave the self-management procedures been pursued enough? Did these procedures provide the patient with suf cient control over the pain and well-being on all daily life situations? Are any medical or other interventions necessary?
Fina l a na lytic a l a s s e s s me nt Final analytical assessment encompasses a re ection of the overall process which has taken place between the physiotherapist and the patient (Box 1.17). This includes information from the initial subjective and physical examination, behaviour of the disorder throughout treatment, responses to various treatment interventions, details derived from retrospective assessments, the state of affairs at the end of planned treatment, taking into account the changes in subjective and physical parameters (asterisks).
Prognos is Making a prognosis may be one of the most challenging skills for a clinician. In the examination and treatment of a patient the clinician frequently needs to estimate how treatment results may be achieved, how long it may take and which concrete results can be achieved. 41
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Box 1.17
Box 1.18
Final analytical assessment
The various phases of prognosis
Final analytical as s es s ment includes the ollowing as pects :
•
•
•
Review o the whole therapeutic proces s , including s tatements o the patient on the individual learning proces s • Re ection on the overall therapeutic proces s : which interventions brought which res ults ? • Re ection on the learning proces s : what was es pecially important to the patient – what has been learned? • The e ectivenes s o any prophylactic meas ures and s el -management interventions . Pros pective view: anticipation o pos s ible di f culties and s trategies to enhance long-term compliance with a regard to advice, s el management meas ures and exercis es : • Compliance enhancement s trategies : which s el management interventions are es pecially benef cial? In which s ituations would the patient anticipate any di f culties in the uture? Which activities /exercis es would the patient res ume in the cas e o recurrence o s ymptoms ? • Sugges tions or any medical or other meas ures that s hould be carried out. • Prognos is on pos s ible remaining unctional def cits in impairment, activity and/or participation levels .
At the beginning o a treatment s eries : •
•
•
What can be achieved on a s hort-term bas is : which res ults can be expected within the f rs t three to our s es s ions ? • What can be achieved on a long-term bas is during the overall proces s o phys iotherapy? • What may not be achieved? During the treatment s eries , es pecially during retros pective as s es s ment in each o the three to our s es s ions , it is es s ential to re ect on all the hypothes es ormed and rejected s o ar in the therapeutic proces s ; the re ection on the prognos is es pecially may aid the clinician to learn pro oundly rom each encounter with a patient and to develop and deepen clinical patterns in memory At the end during f nal analytical as s es s ment – making a prognos is or the time a ter the therapy will be completed cons idering: • •
•
The likely res traints on li es tyle. The likelihood o recurrences o epis odes o the dis order, and the pos s ible early warning s igns the patient mus t heed to minimize the s everity o the recurrence; and the s tep the patient then needs to take. The need or s pecif c ongoing exercis es , intermittent maintenance treatment or ollow-up as s es s ment.
International Classi cation of Functioning, Disability and Health – WHO 2001.
Patients rightfully will seek answers to the following questions, which include queries about prognosis:
• What is wrong with me? • What can be done about it? • H ow long is it going to take? Furthermore, from a physiotherapy-speci c perspective, but also from the viewpoint of insurance companies and referring physicians, endeavouring to answer these questions is essential. When a manipulative physiotherapist makes a prognosis, theoretical knowledge (e.g. tissue healing) and clinical experience (experiential knowledge base) is matched with the clinical presentation of the patient’s problem. Therefore, it contains an element of clinical-pattern recognition, similar to the process of recognizing possible contraindications to treatment. 42
The art and skill of prognosis may appear to be linked to the years of clinical experience and may grow over the course of clinical practice. Nevertheless, novices in the eld can also learn to make prognoses if they explicitly take certain questions into consideration, deliberately make hypotheses about the prognosis throughout the whole therapeutic process and regularly re ect upon them. Furthermore, once they have treated some patients with a similar clinical presentation (e.g. postoperative care of the anterior cruciate ligament of the knee) they will soon be able to forecast what kind of treatment the patient will need, which reactions to expect and how to progress the treatment. This element of a developed clinical pattern will be enhanced if regular reassessment and re ection upon the therapy is performed. The various phases of prognosis are outlined in Box 1.18. In making a prognosis it is essential to bear in mind:
As s e s s m e n t [Prognosis] is an art, or skill, not a science. It concerns probabilities, not certainties and it refers to individual, not the general … Fortunately, although individuals differ in their response to insult, their ailments follow recognised patterns and it is possible to form generalised predictions of the natural history of disorders. (J effreys 1991, cited by Maitland et al. 2005)
Speci c hypotheses categories should also be considered to enhance the prognosis:
• Disorders that are easy or dif cult to help (e.g. • •
•
•
•
complex regional pain syndromes). Nature of the person, including attitudes, beliefs, feelings, values, expectations, (movement) behaviour and so on. Nature of the disorder (intraperiarticular disorders; mechanical osteoarthritis/ in ammatory osteoarthritis, acute injury/ chronic degenerative, nociception alone/ nociception with peripheral neurogenic or central sensitization). The body’s capacity to inform and adapt. (The way the patient ‘feels’ about their disorder often correlates well with other aspects of prognosis. For example: ‘I’ve had knee pain for 20 years so I know I’ll never totally get rid of it’.) Contributing factors and other barriers to recovery (structural anomalies, systemic disease, general health problems such as diabetes, ergonomic/ socioeconomic environments such a keyboard workers, heavy manual work, repetitive unilateral activities at work, little control over work circumstances). Expertise of the physiotherapist, especially in the eld of communication and handling.
The bio-psychosocial model of the ICF (International Classi cation of Functioning, Disability and H ealth – WH O 2001) may serve as an aid in considering aspects of a prognosis (Fig. 1.13). If only function impairments are present, as for example restricted mobility of the shoulder and muscle imbalance with a patient in good health, without large activity limitations, participation restriction and no negative contextual factors, the prognosis will be, of course, much more favourable than when disturbances of all elements would be present. The physiotherapist has to evaluate if discrepancies between the elements of the model are present. In making a prognosis many factors need to be taken in consideration in relation to either short- or long-term goals, such as:
• • • • • • •
•
G eneral health. G eneral tness level. Stage of tissue healing and damage. Mechanical versus in ammatory presentation of the disorder. Irritability of the disorder. Relationship between impairments, activity limitations and participation restrictions. O nset of the disorder, duration of the history, stability of the disorder and progression/ course of the disorder (are attacks more frequent or disabling?). Previous existing disorders and dysfunctions (e.g. a patient has fallen on the shoulder, but may have had degenerative changes in the neck with some pain for a few years).
Health condition
Function (impairments)
Activities (limitations)
Participation (restriction)
Contextual factors • personal • environmental
Fig ure 1.13 • The bio-psychosocial model of the ICF (International Classi cation of Functioning, Disability and Health). Adapted from WHO 2001 . 43
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• Uni- or multicomponential movement disorder (e.g. only local movement dysfunction in the elbow, or the disorder has more components contributing to it: shoulder, cervical and thoracic spine, neurodynamic dysfunction). • Contributing factors – ‘cause of the source’ (e.g. posture, muscle weakness or tightness, discrepancies in mobility of joint complexes such as spine or wrist, etc.). • Cognitive, affective, sociocultural aspects, learning processes (patient’s beliefs, earlier
experiences, expectation, personality, lifestyle, learning behaviour, movement behaviour). • Multidimensional approach to treatment (consideration if the cognitive, affective, behavioural dimension needs to be addressed in treatment). O ver the course of some years of clinical experience, physiotherapists learn to recognize which kinds of clinical presentation react more or less favourably to treatment. These are outlined in Table 1.4.
Table 1.4 Types of disorders
Disorders which may be more easy to help
Disorders which may be more dif cult to help
Recognizable/typical syndrome or pathology. Strong relationship o patient’s symptoms and movement
Weak relationship between the symptoms and movements in the patient’s mind. Atypical, unclear patterns, syndromes or pathology
Predominantly primary hyperalgesia and tissue-based pain mechanisms (nociception; peripheral neurogenic)
Predominantly secondary hyperalgesia rom central nervous system sensitization rather than stimulus-response-related tissue responses
Model o patient: help ul thoughts and behaviours (‘I can still do some things’; ‘I have ound ways to get relie ’)
Maladaptive thoughts and behaviour: (‘I don’t think I ever get better’; ‘I dare not move because it always hurts me’) and other yellow ags
Familiar symptoms which the patient recognizes as tissue-based (‘it eels like a bruise’)
Un amiliar symptoms which the patient has di f culty describing in sensory terms
No or minimal barriers to recovery o predictors o chronicity (‘yellow ags’)
Multi actorial/multicomponent/complex regional pain syndromes
Severity, irritability and nature o the patient’s symptoms correspond to the history o the disorder/to injury or strain to the structures o the movement system
Severity, irritability and nature do not f t with the history or stage in the natural history o the disorder
The patient has had a previously avourable sampling experience with manipulative physiotherapy
Previous un avourable sampling experiences or knowledge o manipulative therapy (‘my mate had manipulation o his shoulder and he said it was much worse a terwards’)
There are easily identif able signs o impairment and activity limitations which have a strong relationship with movement
Evidence o movement impairments but with little correspondence to the degree o activity limitation
Patients are touch-tolerant (gain relie by touch, rubbing or massage)
Patients are touch-intolerant (‘I don’t like anyone touching my knee’)
An internal locus o control (‘I just need to know how I can help mysel ’); locus o control with regard to health and well-being is consistent
An externalized locus o control (‘you are the physiotherapist, you sort me out’) or inconsistency in locus o control with regards to health and well-being
The patient has realistic expectations or recovery which correspond with the natural history o the disorder
Unrealistic expectations or recovery (‘I wish I would wake up and all the pain would be gone’)
The patient will resume appropriate activity and exercise at relevant stages o recovery
Ongoing pain states with little changes in symptoms over a long period o time
44
As s e s s m e n t
At the third or fourth treatment session and the nal analytical assessment, the manipulative physiotherapist should be able to answer the following questions about a patient’s disorder in the quest for a prognosis:
• What is the biomedical diagnosis and what
• • • • •
•
• • •
pathobiological mechanisms are involved? (Tissue mechanisms – pathology, healing processes; neurophysiological pain mechanisms.) What is(are) the source(s) of the patient’s symptoms? What are the contributing factors to the source of the symptoms? (‘Cause of the source’.) To what extent are movements impaired and activities or participation restricted by the symptoms? To what extent is severity or irritability limiting movement and activity? Which predictions can be made about the natural history of the disorder based on its onset, stage of pathological development and pathological stability/ lability? (e.g. healing phases of a lumbar disc.) Which predisposing factors are in uencing the course of the disorder? (Pre-existing pathology, comorbidity, weak link, the nature and extent of injury, age-related processes, general health state, physique, occupation, hobbies, lifestyle, genetic predisposition, etc.) Which factors are contributing to a favourable or unfavourable prognosis? Is the disorder one that will be easy or dif cult to help (based on examination and response to treatment)? What do we understand about the patient’s nature and response to injury and illness? (Adaptive/ maladaptive behaviour; beliefs, thoughts, feelings, attitude, former experiences, values etc.).
In summary, prognosis is a forecast of the future history of a patient’s disorder based on the probability of physical, psychological and functional recovery of the patient and the disorder. Therefore consideration should be given to: 1. The natural history of a particular disorder. (Be cautious as some studies claim that e.g. tennis elbow and frozen shoulder can recuperate over a period of two years;
2. 3. 4.
5.
however, what is the amount of remaining functional impairment?) The response to manipulative physiotherapy – has the progress been acceptable? What is acceptable to the patient – has the main problem been solved? Is there need for prophylaxis – is a selfmanagement programme needed to complement or maintain recovery? Is the patient capable of implementing elements of this programme at adequate moments? Is ‘top-up ‘treatment required periodically? Prognosis should at all times be realistic.
It is essential to maintain at all times a self-critical attitude towards prognosis and regularly pose the same questions as in retrospective assessment if therapy seems to be stagnating:
• H ave I compared the subjective and physical • • • • •
•
parameters (asterisks) regularly enough and in suf cient detail? Did I ensure that the patient would become aware of positive changes in these parameters as well? Did I follow up the correct physical asterisks, which re ect the patient’s main problem and the goal of the therapeutic intervention? H ave I performed a review of the therapeutic process with retrospective assessment procedures, collaboratively with the patient? H as the right source of the symptoms been treated? H ave the self-management procedures been pursued profoundly enough? Did these procedures provide the patient with suf cient control over the pain and well-being on all daily life situations? Did I teach them well enough? Are any medical or other interventions necessary?
Even if physiotherapists embark on a therapeutic process with a less favourable prognosis, they should bear in mind that a prognosis deals with probabilities and hypotheses and should still maintain a positive attitude towards treatment. The following quote relating to neurological rehabilitation may serve as a demonstration of this principle: A positive approach right from the start can contribute greatly to the success of treatment. I nd it helpful when I rst start treating a patient to picture him walking out of the hospital unaided one day, welldressed and waving goodbye with a smile, even if 45
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things look bleak during the early days following his admission. Should a patient not survive the initial trauma or sadly never regain consciousness, nothing will have been lost by the active intervention, but so much gained. All too often I am told that things went so wrong because everyone thought that the patient would not survive for long. Statistical studies concerning prognosis can also lead to negative attitudes, but statistics are not about individuals, and there have been many surprising exceptions. It has been wisely pointed out that the clinician’s attitude may in uence the recovery to the extent that cessation of recovery after 6 months, a widely held belief, may possibly in fact be the result of a self-ful lling prophecy. (Davies 1994)
for member organizations. The purpose of the document is to support each national representative group with their curriculum development and delivery. The standards document gives a detailed insight into dimensions and competencies required by manipulative physiotherapists to practice at an agreed international standard. The IFO MPT Educational Standards Committee identi es 10 dimensions each with three qualifying competencies (knowledge, skills and attributes). Each dimension is relevant to the de nitions of and the paradigm within which O MT is practiced (Box 1.19). Each dimension is quali ed in terms of the three competencies which demonstrate the major
Co mpe te nc ie s rame wo rk and auto no mo us prac tic e Physiotherapy is a competencies-based profession. To ensure best practice is being enhanced by knowledge skills and attributes, physiotherapy competencies need to be framed in relation to:
• Standard of O rthopaedic Manipulative Physiotherapy (O MT) as determined by the International Federation of O rthopaedic Manipulative Physical Therapists (IFO MPT) • Physiotherapists as autonomous practitioners.
OMT and IFOMPT The de nition of O MT (O rthopaedic Manipulative Therapy) as voted by the IFO MPT (International Federation of O rthopaedic Manipulative Physiotherapists) general meeting in Cape Town, South Africa in March 2004 is: O rthopaedic Manual Therapy is a specialised area of physiotherapy/ Physical Therapy for the management of Neuromusculoskeletal (NMS) conditions, based on clinical reasoning, using highly speci c treatment approaches including manual techniques and therapeutic exercises. O rthopaedic Manual Therapy also encompasses and is driven by the available scienti c and clinical evidence and the bio-psychosocial framework of each individual patient. (Beeton et al. 2008)
The IFO MPT Educational Standards Committee headed by Dr Alison Rushton (Beeton et al. 2008) made available an educational standards document 46
Box 1.19 IFOMPT dimensions IFOMP T Dime ns ions Dime ns io n 1: Demons tration o critical and evaluative evidence-bas ed practice Dime ns io n 2: Demons tration o critical us e o a comprehens ive knowledge bas e o the biomedical s ciences in the s peciality o OMT Dime ns io n 3: Demons tration o critical us e o a comprehens ive knowledge bas e o the clinical s ciences in the s peciality o OMT Dime ns io n 4: Demons tration o critical us e o a comprehens ive knowledge bas e o the behavioural s ciences in the s peciality o OMT Dime ns io n 5: Demons tration o critical us e o a comprehens ive knowledge bas e o OMT Dime ns io n 6: Demons tration o a critical and advanced level o clinical reas oning s kills enabling e ective as s es s ment and management o patients with NMS dis orders Dime ns io n 7: Demons tration o an advanced level o communication s kills enabling e ective as s es s ment and management o patients with NMS dis orders Dime ns io n 8: Demons tration o an advanced level o practical s kills with s ens itivity and s pecif city o handling, enabling e ective as s es s ment and management o patients with NMS dis orders Dime ns io n 9: Demons tration o a critical unders tanding and application o the proces s o res earch Dime ns io n 10: Demons tration o clinical expertis e and continued pro es s ional commitment to the development o OMT practice Beeton et al. 2008
C o m p e te n c ie s fra m e w o rk a n d a u to n o m o u s p ra c tic e
functions for performance in clinical practice in each one. Competencies are de ned as: Knowledge: the theoretical and professional understanding, use of evidence, principles, procedures. Skills: the cognitive, psychomotor and social skills needed to carry out predetermined actions. Attributes: the personal qualities, characteristics and behaviour, in relation to the environment. (Beeton et al. 2008). The Educational Standards Committee also presents a clinical practice framework which assures and enables the control of quality delivery of health care within the neuromusculoskeletal speciality and movement therapy health care domains. The standards document also emphasizes the importance of effective clinical reasoning in underpinning high quality clinical practice. Banks and H engeveld (2010) present a clinical practice framework for practice from which a competencies-based
profession has evolved and enable manipulative physiotherapists to think, plan, execute to prove. Box 1.20 represents a feedback method which has been developed within the authors’ clinical practice domain. The aim of the feedback sheet is to match clinical practice to IFO MPT standards of dimensions and competencies. Twenty clinical competencies or measures of performance have been identi ed with supporting criteria. This form of feedback has been valuable in identifying areas of good practice and areas where individuals can focus on their learning needs through continuing professional development (CPD).
Autonomous practice Autonomous practice is de ned by the American Physical Therapy Association (2009) as being ‘characterized by independent, self-determined
Box 1.20 Assessment of standards of clinical practice As s es s ment o clinical practice matched to IFOMPT dimens ions 1–8. There s hould be evidence, in practice, o the criteria below.
•
•
Sub je c tive e xa mina tion •
•
De mo ns trate a patie nt-c e ntre d appro ac h to c linic al prac tic e (dime ns io n 6) The patient is cons is tently given choices The patient is cons is tently included in decis ion making In ormed cons ent is clearly s ought throughout The therapis t recognizes the body’s capacity to in orm and drive decis ion making The clinical reas oning proces s is patient-driven and decis ions made are clearly bas ed on evidence rom the patient There is a ocus on ‘you’ as the patient De mo ns trate a c o llabo rative appro ac h to inte rvie wing (dime ns io ns 6 and 7) • • • • •
Us e o open, unambiguous ques tions Ques tions ocus on the patient experience o their complaint The therapis t lis tens to the patient (i.e. no interrupting, not bombarding them with ques tions ) Directed ques tions are the exception rather than the rule The patient is given an opportunity to tell their s tory
De mo ns trate an atte ntio n to de tail in in o rmatio n g athe ring (dime ns io ns 6 and 7)
•
Detailed analys is o patient’s main problems , body chart (s ymptom areas and nature), behaviour o s ymptoms (including analys is o movement tolerance and acceptance), pres ent and pas t his tory o s ymptoms , relevant medical and health ques tions and ris k actors De mo ns trate tho ug ht ul and e e c tive c o mmunic atio n s trate g ie s (dime ns io n 7) •
• • • • • • •
Attention to non-verbal is s ues s uch as patient/ therapis t pos itions during interview, barriers to communication Attention to developing an e ective therapeutic relations hip (patient at eas e, included) Ques tions as ked with clarity and one at a time Clear meaning to the ques tion Attention to s eeking reliable ans wers Ques tions unbias ed Therapis t recognizes the importance o key words and phras es Need or immediate res pons e ques tions and eedback loops identif ed (‘s o are you s aying that …? ’)
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Box 1.20—cont’d •
•
•
De mo ns trate advanc e d s kills in c linic al re as o ning (hypo the tic o -de duc tive , patte rn re c o g nitio n) (dime ns io n 6) • Multiple hypothes es cons idered and analyzed (deductive reas oning) • Clear us e o knowledge to s upport analys is o clinical evidence • Ability to recognize clear patterns o clinical pres entation (inductive reas oning) • Clear explanation to the patient o f ndings rom interview, examination and treatment, what they mean and what s hould be expected (diagnos tic, narrative, procedural and prognos tic reas oning) De mo ns trate an e xpe rt aware ne s s o di e re ntial me dic al diag no s is and ris k/be ne f t analys is (dime ns io n 2) • Identi y patient’s current medical and health s tatus • Unders tanding o medication • Unders tanding res ults o medical s creening • Awarenes s o di erential diagnos is (mimicking s ymptoms ) • Awarenes s o red ag/yellow ag is s ues De mo ns trate e xpe rtis e in linking the patie nt e xpe rie nc e to phys ic al e xaminatio n as s e s s me nt (dime ns io n 6) • Attention to planning phys ical examination (including agreement and cons ent on s tate o undres s ) • Knowing what tes ts to carry out and to what degree (to P1 or L) • Identi y potential and relevant contributing actors • Any s pecial tes ting needed • Pos s ible interventions
Phys ical Examination •
•
De mo ns trate e xpe rtis e in o bs e rvatio n (dime ns io n 8) • Time allocated to general and s pecif c obs ervation • Recognition o relevant aults • Recognizing what is ideal and what is n’t • E ects o correcting aults on s ymptoms De mo ns trate e xpe rtis e in analys is o unc tio nally de mo ns trate d mo ve me nts (dime ns io n 8) • Linking unctional demons tration directly to complaints • Identi y clear parameters o movement impairment (limitations and res trictions ) • Detailed analys is o the unctional movement
48
•
•
•
•
De mo ns trate e xpe rtis e in s truc tural di e re ntiatio n (dime ns io n 8) • Direct link to analys is o unctional demons tration • Detail o knowledge o s tructure and unction applied to di erentiation • Skill in loading and unloading individual movement s ys tem s tructures (arthrogenic, myogenic, neurogenic) • Reproducibility and reliability o res pons e and handling De mo ns trate a bro ad and de e p rang e o multidime ns io nal c linic al handling s kills applie d appro priate ly (dime ns io n 8) • Detail and range o clinical meas ures adopted (active movement, overpres s ure, palpation, combined movements , motor control s trategies , neurodynamic tes ting, mus cle length s trength, joint motion (acces s ory/phys iological, unctional corners ) s pecif c diagnos tic tes ts , s pecial tes ts De mo ns trate an ability to c le arly link e xaminatio n f nding s to inte rve ntio ns (dime ns io n 6) • Unders tanding o how to merge examination with interventions • Relate interventions to s ubjective and objective data De mo ns trate an ability to us e re s e arc h e vide nc e and kno wle dg e to s uppo rt c linic al de c is io n making (dime ns io n 1) • Relate clinical pres entation, clinical meas ures and interventions to relevant evidence in the literature or knowledge o s tructure, unction and pathobiology • Depth and breadth o res earch port olio
Treatment •
De mo ns trate ac c urac y and s e ns itivity in the applic atio n o a bro ad and de e p rang e o c linic al inte rve ntio n s kills (dime ns io n 8) Attention to detail o : • • • • • • • • •
J oint mobilization techniques Neurodynamic techniques Motor control s trategies Cognitive behavioural/education s trategies Exercis e des ign and application Electrotherapy and kindred modalities Sel -management Rehabilitation Movement capacity and per ormance
C o m p e te n c ie s fra m e w o rk a n d a u to n o m o u s p ra c tic e
Box 1.20—cont’d Re a s s e s s me nt, d oc ume nta tion a nd a na lys is •
•
De mo ns trate an ability to link inte rve ntio ns to appro priate multidime ns io nal o utc o me me as ure s (dime ns io n 6) Es tablis h clear patient-centred outcomes Outcomes related to: • • • •
•
•
•
Impairment Activity limitation Participation res triction Unders tanding the context o environmental and pers onal mediators De mo ns trate an e xpe rt ability to us e re as s e s s me nt as an e e c tive c linic al re as o ning to o l (dime ns io n 6) Details o reas s es s ment: • During treatment • A ter each intervention • Be ore each treatment s es s ion De mo ns trate an ability to do c ume nt as s e s s me nt, e xaminatio n and tre atme nt in line with HPC and CSP s tandards Documentation meets pro es s ional and medico-legal s tandards . Documentation is : • • • • •
Accurate Comprehens ive Logical Methodical Meaning ul
De mo ns trate an ability to re e c t upo n c linic al s kills and the o re tic al kno wle dg e and the appro priate us e o s uppo rting e vide nc e ro m re s e arc h and the bio me dic al, c linic al, be havio ural s c ie nc e s (dime ns io ns 2, 3, 4 and 5) • • •
•
Attribute o re ective practice Identi y s kills and knowledge us ed Identi y and propos e action or s kills and knowledge gaps De mo ns trate an ability to analyze c linic al s kills and the o re tic al kno wle dg e and the appro priate us e o s uppo rting e vide nc e ro m re s e arc h and the bio me dic al, c linic al, be havio ural s c ie nc e s (dime ns io ns 2, 3, 4 and 5) • •
•
Attribute o analytical practice Ability to analyze practice and knowledge in relation to the individual patient • Ability to analyze clinical evidence in relation to knowledge and res earch and vice vers a De mo ns trate an ability to c ritic ally apprais e c linic al s kills and the o re tic al kno wle dg e and the appro priate us e o s uppo rting e vide nc e ro m re s e arc h and the bio me dic al, c linic al, be havio ural s c ie nc e s (dime ns io ns 2, 3, 4 and 5) • •
Attribute o critical apprais al o knowledge and practice Identi y reliable and unreliable evidence
Based on IFOMPT Educational standards, part A, Competencies in OMT 1 – (Beeton et al. 2008).
professional judgement and action. Physical therapists have the capacity, ability and responsibility to exercise professional judgement within their scope of practice and to professionally act on that judgement’. Paris (2008) describes autonomous practice as: (practitioners who are) ‘able to work independently of others appropriate to their education’. The Chartered Society of Physiotherapy (2008) de nes scope of practice as: any activity undertaken by an individual physiotherapist that may be situated within the four pillars of physiotherapy practice where the individual is educated, trained and competent to perform that activity … And (be) supported by a body of evidence.
McMeeken (2007), in a review of physiotherapy education in Australia, acknowledges that physiotherapists in Australia were the rst to practice autonomously and have been doing so since 1976. In the United Kingdom the then Department of H ealth and Social Services (DH SS) issued a code of practice in September 1977. H C (77)33 recognized the rights of allied health professionals, including physiotherapists, to make their own decisions about interventions, progression and discharge of patients referred to their service. The circular also recognized the right of therapists to decline to perform therapies that are harmful to individual patients. The American Physical Therapy Association (2009) outlines the privileges that autonomous practice can bring. These include: 49
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• Development of the patient’s direct and unrestricted access to physical therapy services • The capacity to referral of patients to other medical and health professionals where a patient’s health care needs are beyond physical therapy scope of practice • The capacity to recommend referral for diagnostic test requirements beyond the scope of practice. Autonomy, therefore, demands practice within professional scope and within a culture of interprofessional collaboration. Autonomous practice is clearly enhanced by the clinical practice framework which is underpinned by the ve pillars of clinical practice, the dimensions and competencies matched to IFO MPT educational standards and the recognition of the scope or practice or even extended scope of practice (see Chapter 4).
The bio -ps yc ho s o c ial mo de l o he alth c are The International Clas s if cation o Functioning, Dis ability and Health (WHO 2001) A paradigm shift has taken place in the allied health professions. There has been a signi cant move away from the traditional biomedical model of health care to one that also incorporates other constituents of health such as psychological, social, personal and environmental factors (the biopsychosocial model). Evidence-based or, preferably, evidence-informed practice, forms the basis of clinical guidelines and care pathways for a range of health-related conditions (Childs et al. 2008). Stucki and G rimby (2007) have identi ed a need to organize rehabilitation and related research into distinct scienti c elds. They also recognize that the human functioning sciences should aim to ‘understand human functioning and to identify targets for comprehensive interventions with the goal of contributing to the minimization of the experience of disability in the population’. Lord Darzi, in his Next Stage Review of the NH S in the UK focused on the idea that ‘We can only be sure to improve what we can actually measure’ (Darzi 2008). 50
Bithel (2009) in a preliminary discussion paper on the learning and development strand of the Chartered Society of Physiotherapy focus group on ‘Charting the future’ asks whether there is a need to move the curriculum towards a social model of disability. By using the ICF as an international standard for measuring health and disability Bithel (2009) argues that ICF could become a tool for improving communication between rehabilitation professions as well as with patients and doctors. The World H ealth O rganization’s International Classi cation of Functioning, Disability and H ealth (WH O 2001) has been developed to describe, classify and measure function in health care practice and research. Rundell, Davenport and Wagner (2009) suggest that WH O / ICF appears to provide an effective framework for therapists to prioritize intervention selection by better understanding the patient’s experience. ICF has been linked to: clinical assessment tools (Xiong & H artley 2008); Speci c conditions such as Back pain (Rundell et al. 2009); neck pain (Childs et al. 2008); and goals of interventions (Mittrach et al. 2008). Sykes (2011) recognizes the importance of the ICF as a framework which physiotherapists can use when trying to unravel the multifaceted and multidirectional nature of human function. Sykes refers to its importance in recognizing not only functional defect but also the role that other personal factors and the environment play in determining what mediates an individual’s response to health care issues.
The movement continuum theory o phys iotherapy Banks and H engeveld (2010) have linked ICF to the bio-psychosocial paradigm of physiotherapy practice through the movement continuum approach presented by Cott et al. (1995). Interrelated levels of molecules, cells, tissues, organ systems, body parts, person in the environment and person in the society in uence the movements of a person. It is recognized that external, social and cultural factors, as well as internal, physiological and psychological factors will in uence the movement functions at each level of the movement continuum. Each level has a current movement capacity and a movement potential, which ideally should be the same. In this movement continuum
Th e b io - p s yc h o s o c ia l m o d e l o f h e a lth c a re
Subcellular Molecular
Cellular
Tissue
Body part Organ system Body
Person in environment
Person in society External factors Internal factors Individual/environment interface
Micro Macro Continuum of movement
Fig ure 1.14 • Movement continuum theory: suggested model of body of knowledge of physiotherapy. The levels are interdependent, functions of one level in uence movement capacity of other levels. This model should incorporate all concepts of physiotherapy practice. Reproduced by kind permission from Cott et al. (1995).
all different concepts and methods of physiotherapy should nd their place (Fig. 1.14). Passive mobilization, manipulation and other interventions of manual therapy nd their place at the level of movement of ‘body parts’. This demonstrates that passive movement may play a central role in ‘kick-starting’ active movement and independent functioning of an individual in many movement disorders. H owever, if recovery of full functioning is being achieved, this needs to be determined by regular reassessment, which is another core element of the Maitland Concept of manipulative physiotherapy. O ther movement and associated therapies may need to be included in the treatment programme if functional restoration seems to be lagging behind.
The movement continuum theory and the International Clas s if cation o Functioning, Dis ability and Health (ICF) The movement continuum theory (Cott et al. 1995) may become the theoretical model which underpins clinical practice and guides research. H owever, in daily practice such a model may not be suitable for making a physiotherapy diagnosis, as the microlevels describe aspects of movement which cannot be directly observed within the routine clinical examination. Therefore, diagnosis in physiotherapy may be expressed in terms of movement dysfunctions using the levels of disability as described in the
International Classi cation of Functioning, Disability and H ealth (ICF) (WH O 2001) (Box 1.21, Fig. 1.13). The analysis of movement-impairment has been the original domain of manual therapists, in which passive movement and manipulation frequently play a central role. Figure 1.15 delineates a model in which manual therapists may be able to
Box 1.21 ICF domains •
•
•
•
Functions are the phys iological or ps ychological unctions o body s ys tems • Body s tructures are anatomical parts o the body s uch as organs , limbs and their components • Impairments are problems in unction or s tructure s uch as s ignif cant deviation or los s Activity is the execution o a tas k or action by an individual • Activity limitations are di f culties an individual may have in executing activities Participation is involvement in a li e s ituation • Participation res trictions are problems an individual may experience in involvement in li e s ituations • Environmental and pers onal actors make up the phys ical, s ocial and attitudinal environment in which people live and conduct their lives Health condition: any pathobiological proces s in uencing the levels o unctioning
WHO, 2001
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Participation – social roles
Individual illness experience (prioritizing treatment goals)
Activities – resources/restrictions Precautions Contraindications
Joint
Muscle functions
functions
Neurodynamic functions
Treament goals
Movement impairments Pathobiological processes Stages of tissue healing
Others: blood vessels, viscera
Soft tissue functions: skin, fascia, connective tissue
Fig ure 1.15 • Model of ICF in which manual/NMS physiotherapists integrate the speci c taxonomy of the analysis of movement impairments. Adapted from Hengeveld 1999 with permission.
integrate their speci c body-of-knowledge and practice into the model of the ICF (H engeveld 1998, 1999). This model presented here may further serve to support comprehensive treatment objectives at all levels of disability, in which the individual illness experience (Kleinmann 1988) will be the priority in goal-setting. With the ICF model, the speci c strengths of allied health professions can be maximized. For example, community physiotherapists and occupational therapists have developed skills in rehabilitation at the level of activities and participation. Manipulative physiotherapists utilize their manual and rehabilitation skills within all of the ICF domains and levels of the movement continuum including: physical impairment (e.g. muscle weakness); activity limitations (e.g. walking); and participation restriction (e.g. playing tennis). Within these domains the impact of environmental and personal contextual factors (e.g. beliefs and attitudes and employment circumstances) on how health is mediated are always considered (Fig. 1.15).
profession in the nineteenth and twentieth century accepted medical hegemony and adopted biomedical perspectives in their work to support their professional recognition and permission to practice (Parry 1997, Barclay 1994, Welti 1997). O ver the past decades, however, the biomedical model has been challenged, both in the elds of medicine and physiotherapy. Engel (1977) challenged the biomedical model, by arguing that it placed too much emphasis on pathology without consideration of the psychosocial impact of illness and disease. From a bio-psychosocial perspective it is suggested that various factors may contribute to the development and maintenance of disease, pain and disability: • Biological processes • Emotional aspects • Cognitive aspects • Social factors • Cultural factors • Behavioural factors.
From a medical to a bio-ps ychos ocial paradigm
The role o the biomedical model in manipulative phys iotherapy
In the past physiotherapy practice and research has been in uenced by the biomedical paradigm. H istorically, the founders of the physiotherapy
In spite of the shift in paradigm towards biopsychosocial models, biomedical thinking (Box 1.22) still has an important role to play in
52
Th e b io - p s yc h o s o c ia l m o d e l o f h e a lth c a re
Box 1.22 The role of the biomedical model The biomedical model has value in: •
•
•
Es tablis hing a medical or orthopaedic diagnos is as an initial point o re erence or manipulative phys iotherapy Medical s creening to determine contraindications and precautions to examination and treatment procedures Prognos is making – es timating the natural his tory o healing and recuperation
the clinical reasoning processes of manipulative physiotherapists, for example, in the need to establish precautions, contraindications and the limitations of scope of practice. The role of the bio-psychosocial model is outlined in Box 1.23.
International clas s if cations o dis eas e (ICD) and unctioning, dis ability and health (ICF) and the brick wall concept It is also possible to place the ICF in the context of the clinical practice framework of the Maitland Concept through the symbolic permeable brick wall model of compartments of theory and clinical practice as detailed in Table 1.5. O nce again, the symbolic permeable brick wall model ensures that the physiotherapist can keep facts and evidence about disease and functioning separate from one another. An understanding of disease processes is a requirement of the brick wall. This understanding, however, should be independent of and not be the driver of, the physiotherapist’s ability to make decisions on how to restore a patient’s functional capacity and physical performance. The domain of physical health
Box 1.23 The role of the bio-psychosocial model Bio-ps ychos ocial paradigms are now central to manipulative phys iotherapy clinical reas oning, particularly in determining management approaches , s uch as thos e that relate to: •
The individual illnes s experience (Kleinmann 1988) and the individual’s rame o re erence and the ways in which they have learnt to deal with illnes s • Communication s kills between patient and therapis t. Attentive lis tening and obs ervation o ten give an ins ight into the world o thoughts , eelings , attitude, values , earlier experiences , behaviour o the patient with regard to the dis order • The ps ychological and s ocioeconomic variables in the human experience and how they are more likely to contribute to ongoing pain and dis ability rather than be a caus e o them (Kendall et al. 1997) The es s ential components o the bio-ps ychos ocial paradigm are: • • •
• •
A client-centred attitude, with empathy, unconditional regard, genuinenes s (Rogers 1980) Ability to employ various communication s kills Collaborative goal s etting, joint def nition o parameter to monitor treatment res ults and s election o treatment interventions with the patient Choos ing treatment interventions which are meaning ul to the patient Explanation, in ormation and educational s trategies to enhance unders tanding, motivation and conf dence to us e the body again
•
Awarenes s o behavioural changes : as manipulative phys iotherapis ts requently ollow objectives to change (movement) behaviour, it is important to realize that behaviour will not change overnight. Ins ights rom cognitive behavioural therapy are help ul in the guidance o a patient in this proces s o change • A salutogenetic pers pective as complementary to a pathogenetic pers pective. While a pathogenetic pers pective mainly ocus es on caus ative actors and the prevention o dis eas e and other dis orders , a s alutogenetic pers pective concentrates on ques tions as to why people s tay healthy in s pite o the pres ence o certain s tres s ors and which actors help to guide people to f nd a better s ens e o health. As s tated by Antonovs ky (1979) ‘s alutogenetic actors are not neces s arily the other s ide o the coin o pathogenes is ’. Other actors , as s ummarized in the term ‘Sens e o Coherence’ (with the elements o comprehens ibility, meaning ulnes s , manageability), play a role in the ques tion o why people maintain a s ens e o health and well-being in s pite o the pres ence o s tres s ors . The role o manipulative phys iotherapis ts is to guide patients towards a s ens e o health with regard to movement unctions . Hence, within pro es s ional practice a s alutogenetic orientation is already pres ent.
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Table 1.5 ICF in context of the symbolic permeable brick wall
Neuromusculoskeletal Movement-related conditions disorders ICD-10 (International Classif cation o Disease) • • • • • •
Biomedical diagnosis Pathobiology (disease) Caus e s Trauma Degeneration Disease
ICF (International Classif cation o Functioning, Disability and Health) • Bio-psychosocial • Functional (per ormance and capacity) • Impac t • Impairment (body structure and unction) • Activity limitations • Participation restrictions • Contextual actors (personal and environmental)
is, in essence, what de nes the physiotherapy scope of practice.
The bio-ps ychos ocial paradigm and healthy living Moore and Jull (2010), in an editorial, encourage physiotherapists to embrace the challenges to manipulative and movement therapies, which have been driving the changing complexities of health economics and the changing needs of the populations of most countries. The changes in provision of health care have enabled physiotherapists to focus on quality, innovation, productivity and prevention in the design of their services. Physiotherapy is becoming an important feature of the public health domain whereby the patient is empowered to take ownership of their health in partnership with their health care professionals. H igh quality clinical skills remain central to these demands. O utcomes are now the focus of quality within health care (Department of H ealth 2010). This means that by being able to link patient-reported problems to functional de cit and then by designing health care around interventions which lead to successful functional outcomes, physiotherapists’ skills in assessment and clinical reasoning are pivotal. The clinical practice framework presented in this chapter provides an ideal model to meet these changing needs and demands. 54
Health care
Healthy living
Five pillars
Functional capacity and performance [ICF]
Competency Biopsychosocial
Physical and mental wellbeing
Fig ure 1.16 • The health care/healthy living interface.
Physiotherapists and other health care professions have a strategic role at the health care, healthy living interface. Fig. 1.16 demonstrates how skills and knowledge in the neuromusculoskeletal and movement disorder domain can provide effective health care and support the individual in a return to healthy living, the health advantages of which are all too clearly evident. Ultimately physical and mental health and wellbeing are constituents of and help to promote life expectancy (adding years to life) and above all healthy life expectancy (adding life to years) (Middleton 2008).
Re s e arc h and the Maitland Co nc e pt Well-designed research is now an established partner of clinical practice and underpins the daily working activity of manipulative physiotherapists (Jones et al. 2006b). Reliable evidence relevant to manipulative physiotherapy practice is enhancing professional accountability to service users, the public at large, medical and health care peers and the scienti c community as a whole. The Maitland Concept and its features have not been immune from research. In many research papers, designed to measure the reliability and effectiveness of manipulative physiotherapy interventions, the techniques described in such detail by Maitland (1986, 1991) are used as methodological reference standards (Maricar et al. 2009, Fujii et al. 2010, Courtney et al. 2010). Features of the Maitland Concept which have been subject to varying degrees of academic and experimental scrutiny include:
• Passive movement • Irritability
Re s e a rc h a n d th e M a itla n d C o n c e p t
• G rades of mobilization and manipulation • Dosage parameters of mobilization and manipulation • Movement diagrams • Assessment/ reassessment and appraised.
Pas s ive movement Maitland (1987) was always a great advocate of the use of passive movement as a therapeutic intervention. Maitland always understood the context of the use of passive mobilization or manipulation within the whole therapeutic process. The demand was that the technique achieved its desired effect and that effect was measurable through detailed subjective C/ O and physical P/ E markers. If the technique did not achieve its clinical effect then G eoff Maitland was open to different, new and innovative ways of helping the patient. For example, the authors of this chapter once saw him treat a woman with a painful arthritic knee who was not responding to accessory mobilization. H e asked the women to lie on a mat on the oor, he used his sternum to apply a compressive force through the knee whilst mobilizing it into extension and adduction. Maitland believed that ‘assessment examination and treatment by passive movements’, if carried out with empathy, detail and skilled application would support the patient in being able to move with less pain or with greater mobility. H e also believed that passive movement had a different therapeutic effect to active interventions alone. Zusman (2010) in a perspective on passive movement used analysis of existing research to support a hypothesis that manual application of passive mobilization techniques can ‘facilitate optimal repair and tissue integrity when applied to healing soft tissue’. Zusman discusses the present knowledge about the intrinsic sensitivity of connective tissue cells to mechanical stimuli such as stretch, pressure and glide. The implication for passive movement as a therapeutic intervention is also noted. Connective tissue is known to need regular mechanical stimuli to enhance and maintain tissue health. Evidence is clear (Van Wingerden 1995) that stress deprivation leads to unhealthy and therefore potentially painful tissue. Zusman (2010) concludes that there is emerging knowledge about how passive movement is likely to be bene cial to optimal healing of recently traumatized tissue. Speci c tissue perturbations could
facilitate and optimize repair by providing a speci c external ‘anchor point’ needed to enhance the structural and biochemical events associated with healing and growth. Although related to exercise prescription, Khan and Scott (2009), in a review article, detail how the body converts mechanical loading into cellular responses and structural changes by ‘Mechanotransduction’. Shear and compression loading of tissues is thought to cause physical perturbations of the cells that make up the tissue. Evidence from studies on tendon, muscle, cartilage and bone suggest that, ‘mechanical stimulus on the outside of the cell promotes intracellular processes leading to matrix remodelling’. The message here is that ‘Mechanotherapy’, including mobilization and manipulation as well as exercise, has a role to play in promoting tissue healing. This analysis may well be the ‘something different’ that Maitland always considered set passive mobilization aside from other forms and uses of therapeutic movement (Box 1.24).
Irritability Box 1.25 de nes the term irritability (Maitland et al. 2005) along with the original de nitions of its companions – severity and nature.
Box 1.24 De ning passive movement Any movement (o a joint or vertebral s egment) which is produced by any means other than the particular mus cles related to the particular joints or vertebral s egment’s movement is a pas s ive movement. It includes mobilization and manipulation.
Mob iliza tion This is a ‘pas s ive movement’ but its rhythm and grade are s uch that the patient can prevent it being per ormed.
Ma nip ula tion Loos ely def ned as any kind o ‘pas s ive movement’ us ed in examination and treatment. A s mall amplitude rapid movement (not neces s arily per ormed at the limit o a range o movement) which the patient cannot prevent rom taking place. Maitland et al. 2005
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Box 1.25 Severity, irritability and nature de ned (SIN) Se ve rity A s ymptom is def ned as being s evere i the activity that caus es the pain needs to be interrupted and s topped becaus e o the intens ity o the pain. In many cas es this is an indication that caution is needed with examination and treatment procedures .
Irrita b ility Irritability re ers to the amount o s timulus (activity, pos ture, etc.) required to provoke s ymptoms , the s everity o thos e s ymptoms and the time they take to s ettle once the s timulus has been dis continued. Like mos t things , it exis ts as a continuum. A very irritable pres entation means that a little activity caus es a lot o pain that takes a relatively long time to s ettle. In many cas es this is an indication that caution is required during examination and treatment procedures .
Na ture o the d is ord e r a nd the p e rs on As pects o a problem that require cons ideration in examination and treatment procedures may include the pathobiological proces s es underlying the dis order, contributing actors s uch as os teoporos is , s tage o healing, s tage and s tability o the dis order and certain pers onal eatures s uch as ear o moving.
Smart and Doody (2007) using a qualitative semistructured design research method, interviewed experienced physiotherapists. The purpose of the study was to investigate their clinical reasoning strategies in relation to pain presentations. Through the interviews of seven participants evidence emerged that clinical decisions are based on an evaluation of severity and irritability from the information on pain reports. In particular, assessment of irritability was used to help decide on the extent of any physical examination. And, with severity, there was evidence of the concept of severity and irritability in uencing decisions on planning the extensiveness of subsequent treatment. The purpose of such reasoning about severity and irritability seems to be grounded in the clinician’s desire to avoid exacerbation of symptoms as a result of examination and treatment. Smart and Doody (2007) conclude that their study supports the use of severity and irritability as a clinical reasoning tool even though there is little evidence of such concepts being explored elsewhere in the literature other than in textbooks. 56
Barakatt et al. (2009) speci cally explored the concept of irritability in patients with low back pain. In a cross-sectional design study, a sample of 183 patients with low back pain (LBP) were recruited from three physical therapy clinics and rst asked to complete a series of disability and beliefs questionnaires and a pain-rating scale. Participants were then examined and treated according to practice standards. Therapists were then asked to record their irritability judgement of the subject’s low back pain. The study ndings indicate that LBP characteristics as identi ed through disability questionnaire, the presence of peripheralized symptoms and movement analysis (forward bending) are all associated with therapists’ judgements of irritability as proposed by Maitland (1986).
Grades o mobilization and manipulation Whilst idiosyncratic (Zusman 2010) grades of mobilization are accepted in many manipulative physiotherapy quarters as a working model for the re nement and documentation of mobilization techniques (Maitland et al. 2005) (Box 1.26). There are many instances in the experimental design research and clinical practice guidelines where techniques described by Maitland are used as the methodological standard for trials which evaluate the effects of mobilization on a range of peripheral conditions (Maricar et al. 2009, Fujii et al. 2010, Courtney et al. 2010). G rades of mobilization are also described in research which aims to determine the effects of mobilization on pain and dysfunction (Moss et al. 2007). Chester and Watson (2000) recognize that physiotherapists typically use rhythmical oscillatory passive movements to treat symptoms of pain and stiffness. Chester and Watson also consider grading as a benchmark against which treatment and progression can be planned. Jull (2002) acknowledges that the manipulative therapy approach developed by Maitland has underpinned the practice of Australian Physiotherapists for over 50 years and, an audit of treatment protocols for patients with cervicogenic headache from within a multicentre randomized trial, demonstrates that, where manipulative therapy was being applied in practice, both high velocity manipulation and low velocity mobilization treatment techniques were used.
Re s e a rc h a n d th e M a itla n d C o n c e p t
Box 1.26 Grades of mobilization de ned Pos ition in range and amplitude (grade) • •
•
•
•
•
Grade I: a s mall amplitude movement per ormed at or near to the beginning o the available range Grade II: a large amplitude movement per ormed within the resistance-free part o the available range (in this cas e res is tance which is f rm and s tarts to limit the movement) Grade III: a large amplitude movement per ormed into f rm res is tance or up to the limit o the available range Grade IV: a s mall amplitude movement per ormed into f rm res is tance or up to the limit o the available range Grade V: a s mall amplitude high velocity thrus t movement localized to a s ingle joint or vertebral s egment us ually but not always near the end o the available range (always within the phys iological limits o the joint’s movement) Grade V manipulatio n te c hnique s , as def ned above, s hould be us ed mainly or progres s ion o treatment when mobilization techniques to treat s ti nes s o vertebral s egments are no longer e ective. grade V techniques require care and experience in s election and application. The detail o the principles and practical application o grade V techniques are beyond the s cope o this text and s hould only be applied clinically a ter adequate training and practice in accordance with Pro es s ional Codes o Practice.
Bazin & Robinson 2002
Rollins and Robinson (1980) in a pragmatic, noncontrol study evaluated student-physiotherapists’ understanding of the grading system (I-IV developed by Maitland). After training and instruction on how to perform grades, students were asked to identify grades performed by an experienced instructor on a videotape. G rades were also performed on students by the instructor. The technique used was the anteroposterior glenohumeral mobilization technique described by Maitland (1991). In this study, out of 720 grades of mobilization randomly allocated there was a 94.5% visual accuracy and 91.7% kinaesthetic accuracy in identifying the correct grade. Although the methodological quality of this study does not hold up to scrutiny, it still provides a snapshot of the potential for the use of grades in skills acquisition and therefore greater competency in therapeutic application.
An example of the use of grades in research related to potential effectiveness of mobilization therapeutically is provided by Fujii et al. (2010). In a cadaver study Fujii et al. explored the effect of mechanically generated distal tibio bular joint mobilization on ankle dorsi exion range of movement. The force applied to the tibio bular joint equated to a grade III mobilization as described by Maitland (1991) leading to a signi cant increase in cadaver range of ankle dorsi exion. Although the study is not directly related to patient treatment it demonstrates how the grades of mobilization are being used as methodological standards in research. In a clinical trial with a control group Courtney et al. (2010) used a grade III posteroanterior knee mobilization technique as described by Maitland (1991) to evaluate the effects this may have on exor withdrawal response in patients with knee osteoarthritis. This low-powered study demonstrated a signi cantly reduced nociceptive re ex response (electrocutaneous stimulation) after joint mobilization. Whilst the inferences from this study are limited or non-existent there is still value in recognizing that a strong debate is going on within the physiotherapy world about the clinical, neurophysiological and functional value of graded passive mobilization techniques in conjunction with other interventions. In a single-case design, Maricar et al. (2009) investigated the effects of exercise and exercise with mobilization on shoulder mobility, function and pain. The mobilization method consisted of the application of grade IV anteroposterior mobilization in exion and longitudinal caudad mobilization in abduction on a population of patients with adhesive capsulitis. The study found that there was improvement in pain, function and range of movement with both exercise and exercise with mobilization. Range of movement improved more so with exercise and the addition of mobilization. Nelson and H all (2011) used lumbar accessory movements to identify segmental hypomobility in a case report of a young tennis player with bilateral dorsal foot pain. G rade III− and grade III unilateral posteroanterior mobilization techniques were used in combinations with lower extremity neurodynamic treatment techniques to effect successful neurodynamic management of this particular young patient. The successful management of this patient is attributable to an attention to detail in clinical 57
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reasoning and the application of reliable manual skills and treatment techniques.
Dos age parameters o mobilization and manipulation A grey area of evidence when selecting and applying oscillatory passive mobilization techniques is in relation to dosage parameters. H engeveld & Banks (2005) suggest that techniques which are designed to have an immediate modulating effect on severe or irritable movement related pain should be:
• G raded I or II • O f a slow smooth rhythm • O f short duration, performed for up to two minutes • Repeated only once or twice in a session. Whereas techniques which are designed to have an effect on movement related stiffness and pain should be:
• • • •
G raded III or IV O f a quicker, sharper staccato rhythm Performed for several minutes Repeated several times within a session.
G rade V manipulation techniques of peripheral joints are not the main focus of this text and are described in more detail in other texts (Kesson & Atkins 1998). The parameters of a grade V, however, are that they should be of small amplitude and high velocity and only performed up to three times over a number of sessions to achieve their desired effects. Zusman (2010) suggests that it may be time for the physiotherapy profession to revisit arbitrarily arrived at parameters of passive mobilization such as frequency, delivery and time span of use in order to maximize the emerging knowledge of how speci c tissue and cellular mechanical perturbations could facilitate optimum tissue repair. Table 1.6 details the studies and trials that have used passive mobilization techniques and which have had an immediate effect on pain, movement and function. The treatment parameters are outlined and the reasons behind the selection of these parameters are given. Analyzing the evidence presented in experimental design studies may serve as evidence to inform decisions about technique selection and progression. 58
Movement diagrams Movement diagrams were developed within the Maitland Concept ‘solely as a teaching and communication aid’ (Maitland 1991). The idea was for the movement diagram to serve as a ‘dynamic map’, whereby clinicians can analyze passive movement, (e.g. hip exion/ adduction), in terms of available range and the relationship between clinical features such as pain, resistance (stiffness) and spasm with movement. With this analytical understanding the clinician can then make a link to the reasoned application of appropriate grades of mobilization. Figures 1.17 and 1.18 remind the reader how a movement diagram can be constructed. Evidence in the literature demonstrates that attempts are being made to validate movement diagrams as tools for pain and motion indicators (MacDermid et al. 1999), as a measure of treatment effectiveness (Conroy & Schneider 2005), and as a tool to try to enhance intertherapist reliability in performing grades of movement through a greater understanding of R1 perception (Cook 2003). MacDermid et al. (1999) in a blind clinical trial demonstrated the use of a movement diagram to assess passive lateral rotation of 34 patients with a variety of shoulder conditions. The study found a correlation between movement diagrams and range of movement assessed with goniometry. There was also a correlation between pain scores and movement diagram recorded pain onset and intensity as well as impairment measures from the movement diagram and patient-rated shoulder disability. There is good reason, therefore, to consider movement diagrams as providing relevant information about movement impairment and pain in patients with shoulder conditions. In a case presentation on T4 syndrome, Conroy and Schneider (2005) explored the use of a movement diagram to establish the segmental impairment (pain and stiffness) attributable to symptoms associated with T4 syndrome. In this case, the value of the movement diagram was to ensure the correct segment was treated and the grade of posteroanterior mobilization on the thoracic spinous process was appropriate to the pain and stiffness impairments identi ed by the diagram. Conroy also explored the relationship between the changes in the parameters of the movement diagram with the change in symptoms.
Re s e a rc h a n d th e M a itla n d C o n c e p t
Table 1.6 Parameters of mobilization and manipulation treatment techniques
Citation
Technique
Grade, speed, rhythm, duration
Selection reasoning
Courtney et al. (2010)
Posterior to anterior accessory mobilization techniques on the tibia with the knee in 20 degrees o exion
Grade III Pain- ree range 45 oscillations per minute Six minutes duration Reassessment within 15 seconds
Use o a rhythmical oscillation or joint pain. Assessment o exor withdrawal re ex as a measure o nociceptive excitability in the presence o osteoarthritis o the knee
Fuji et al. (2010)
Simulated cadaveric posterosuperior mobilization o the lateral malleolus
Grade III 30 N orce calculated to produce 2 mm o movement o the f bula Cyclical loading rom 15–30 N 15 N per second speed 1000 cycles
Use o a grade III large amplitude movement to improve the range o dorsi exion o the ankle o cadaver specimens
Wang & Meadows (2010)
C5/6 Lateral glide mobilization on the right side
Grade III One to two times per second Five minutes duration
Use o mobilization technique to reduce inhibitory stimuli rom the spine causing inhibition o lateral rotation strength o the shoulder
Maricar et al. (2009)
Anteroposterior mobilization o the glenohumeral joint in 90 degrees o shoulder exion Longitudinal caudad mobilization o the glenohumeral joint in 90 degrees o shoulder abduction (both techniques per ormed with grade I distraction)
Grade IV Two to three oscillations per second Approximately 30 seconds Repeated i reassessment improvement was noted
Use o end-o -range and small amplitude mobilization techniques to increase shoulder range o motion in patients with adhesive capsulitis
Jull (2002)
High (manipulation) and low (mobilization) velocity techniques to the cervical spine
Eight to 12 treatments over a six-week intervention period
Commonly used treatment techniques or patients with cervicogenic headaches
Herzog (2000)
High velocity, low amplitude cervical spinal manipulative thrust
Typical duration o 100–200 ms Typical orce o 100–150 N
Used to produce a number o e ects including a temporary increase in the degree o displacement available within a joint
Cook (2003) used the concept of movement diagram construction to explore whether its use as a preperceptual teaching tool helped therapists inter-rater reliability in performing grades of mobilization. There was no evidence that this was the case in this study. H owever, the author of the study does recognize the intrinsic motor variables of each individual therapist and the dif culties this poses for the universal perception of grades of mobilization.
Reas s es s ment Assessment and reassessment is the keystone that holds decision making together within the Maitland Concept. Attention to detail in assessing changes in a patient’s signs and symptoms with treatment is the requirement of the Concept and is integral to the discipline of recording the effects of treatment to evaluate: 59
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R2(IV+)
D
P’(loc, sev)
A
R1 P1(loc)
L
B
T4–5 AB = A passive movement direction (physiological, accessory, combination) A = Any starting position B = End of average normal range (B is naturally variable and is depicted as a thickened line) AC = The quantity, quality, nature and intensity of the factors being plotted CD = The maximum quantity, quality, nature and intensity of the factors being plotted R1 = The start of perceptible resistance to movement R2 = The maximum quantity of resistance allowable A–R1 = Friction free feel R1–R2 = The end feel (hard, soft, etc.) L = Pathological limit of range H = Average normal end of hypermobile range
Fig ure 1.17 • Dimensions and features of movement diagrams. Reproduced with permission from Banks & Hengeveld 2010. R2(IV+++)
C
D
P'(local intensity)
A
R1
P1 L (local)
Tibiofemoral extension
B
• Define parameters • Choose direction for testing • Find P1 (approx/exact) • Qualify P1 • Find limit (L) • Qualify L (R2) • Find R1 • Find and qualify P' • Connect P1 to P' • Connect R1 to R2 • Define clinical group and role of mobilization
Fig ure 1.18 • Constructing a movement diagram. Reproduced with permission from Banks & Hengeveld 2010.
• The effects of treatment during the previous • • • •
session Planning of the next session Effects of treatment whilst it is being performed Immediate effects of treatment Effects in between treatment sessions.
Figure 1.19 demonstrates the documentation of recording of a treatment. 60
Tuttle (2005) recognizes that physiotherapists use within-session changes in patients’ symptoms and signs to help guide and re ne treatment and management plans. Tuttle explores the seemingly face validity of Maitland’s assessment and reassessment of range of movement, for example, as an indicator of manipulative physiotherapy treatment. The clinical trial explores whether within-session changes in cervical range of movement in patients with neck pain
Re s e a rc h a n d th e M a itla n d C o n c e p t Examples Passive movement Rx G/H Supine In: 150° F (before P1) Do:
lat.
IV - IV Smooth rythm, rel, quick Totally ca. 6’
C/O: ‘same’ P/E: F 160° L IV++ (feels much freer. I can move higher) HBB: range ISQ, P ISQ Plan: repeat same Rx: if HBB remains ISQ, do acc, mvt in EOR HBB
‘comfortable’: after 4’ R1 to L, especially with – after ca 6’ no furhter changes in P or R
Other forms of treatment: Exercises In sitting: do F/Ad hip ri and le. 5x, ca 10, til slight pulling buttock ‘comfortable’
C/O: ‘lighter than before to stand’ P/E: LxF: 2cm _ ac1 EOR Hip F: 130° I IV+ Plan: do ex. at home/work: at least 3x/day AND when P buttocks starts 1–2 series: 5x/30 each leg
Ultrasound Sitting knee extended Rx: US 3 MHz large head; 1:2 int. 1.0 W/cm2, 3’; on tender spot, medially knee No pain
C/O: ‘not tender now’ P/E: Squat: full ranage _ E/AB: , I IV+ (frequently it is useful to compare the results and to mark which elements may have improved folowing the intervention)
Fig ure 1.19 • Example of recording treatment. Reproduced with permission from Banks & Hengeveld 2010.
predict between-session changes in the same. The study of 29 subjects found that within-session changes in range are predictors of between-session changes and therefore a positive outcome. This study, therefore, demonstrates that explicit evaluation of changes in range of movement during treatment is important in the process of planning progression of treatment towards a successful outcome. In a further longitudinal observational study of patients with neck pain, Tuttle et al. (2006) demonstrated that changes in impairments of movement during the rst two treatment sessions using manipulative physiotherapy can help to predict outcomes in impairment (range of movement) but not
in activity limitations (disability index and functional scales). The inferences from this study support Maitland’s view that gains during treatment should be translated into functional gains with an emphasis in assessment, not only of range of movement (P/ E asterisks), but also on the 24-hour behaviour of symptoms between sessions. In this way an analysis and evaluation of both impairments and activity limitations can be identi ed and dealt with not only with manipulative therapy but with other more active functional exercise strategies. Maitland would always ensure that treatment had functional carryover with a well-designed and appropriate home programme. 61
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Cook et al. (2012) followed up these studies by investigating the long-held clinical observation that when patients’ pain and movement improve with exploratory manual therapy treatment (mobilization and/ or manipulation) during initial assessment and at subsequent follow-up visits, this provides good evidence that the patient has and will respond well to manual therapy intervention. Cook et al. (2012), therefore, carried out a secondary database analysis of a randomized clinical trial. This study of patients treated with manipulation and mobilization for low back pain tried to establish whether within-session changes (improvement in either pain and mobility during a single visit) and between-session changes (carry-over improvement at subsequent visits) were experimentally associated with self-reported functional improvement, pain reduction and enhanced recovery. If this association was present, a further objective was to determine the extent of change needed to establish this association between withinsession or between-session changes and functional recovery. If patients exhibited within-session changes in the reproduction of their symptoms with a unilateral posteroanterior movement or a central posteroanterior movement, they progressed to the treatment phase. All patients (N=102) were then treated by experienced physiotherapists with manual therapy, home exercises and other modalities as they would be in clinical practice. Selfreported ndings (numerical pain rating scale, O swestry disability questionnaire, rate of recovery and within-session or between-session scores for pain) were then collected (on initial assessment) after two visits and on discharge. The results of 100 patients who progressed to discharge suggest that if patients report a signi cant within-session or between-session reduction in ndings, this is useful in determining who will most bene t functionally. There is no signi cance, however, in within-session or between-session changes and high self-reporting of rate of recovery.
The authors acknowledge that inferences cannot be drawn from this study as there was no control group and the lack of impairmentbased outcome measures, such as range of movement, limits the true clinical application of the study results. They concluded, however, that evaluating withinsession and between-session changes in self-reported ndings, complements clinical decision making in that it provides evidence of who is likely to respond to manual therapy treatment.
The oxymoron that is the Maitland Concept The clinical practice framework presented in this chapter contains all the features of the Maitland Concept as presented by G eoff Maitland (1987). The framework is designed as a structure that is transferable into clinical practice. Whilst it does not give all the answers it helps manipulative and movement therapists to operate effectively in the domain of NMS and movementrelated disorders (WH O 2001). The framework for clinical practice developed by G D Maitland, up to the point of his retirement, is an oxymoron in many ways. G eoff Maitland, himself, was ercely passionate about manipulative physiotherapy yet gentle and caring in his relationship with all his patients. The Concept re ects this in being stubbornly adaptable in its principles. It demands a scienti c artistry to its skills. It allows logical laterality in thinking. It is complex in its detail yet simple in its desired effects. These are the strengths of the Maitland Concept and if it is used in a way that provides a rm and immovable structure and yet is able to embrace change and progress then it will serve its purpose and be sustainable and accepted for another 50 years or more.
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Conc lus ion
84
Key words Movement continuum theory, ICF, evidence-bas ed practice, client centerednes s , paradigms of movement-analys is and treatment
Intro duc tio n In the past ew decades the science o physiotherapy has established itsel in the eld o the movement sciences. It has become accepted that physio therapists ollow a speci c movement rehabilitation paradigm within a bio psychosocial ramework (C SP 1990, CPA 1992, KNG F 1998, APTA 2001). The roots or this perspective are inherent to the pro ession, however, it was H islop’s groundbreaking lecture, which laid the oundation or movement as the core o the declarative knowledge o the pro es sion (H islop 1975). She proposed a cybernetic model with a hierarchy o unctions or the research, analysis and treatment o human motion. Cott et al. (1995) have elaborated on H islop’s model with the movement continuum theory o physiotherapy 66
(Fig. 2.1). Interrelated levels o molecules, cells, tissues, organ systems, body parts and physical and social environment all have an inf uence on a per son’s movement unctions. It is recognized that external, social and cultural actors, as well as inter nal, physiological and psychological actors inf uence the movement unctions at each level o the move ment continuum. Each level has a current move ment capacity and a movement potential, which ideally should be the same. In this movement con tinuum all the di erent concepts and methods o physiotherapy should nd their place. The World Con ederation o Physical Therapy (WCPT) also recommends ollowing a movement paradigm and adheres to Cott et al.’s movement continuum theory by pointing out that: [Physiotherapy] is concerned with identi ying and maximizing movement potential within the spheres o promotion, prevention, treatment and rehabilitation. This is achieved through interaction between physical therapist, patients or clients and caregivers, in a process o assessing movement potential and in working towards agreed objectives using knowledge and skills unique to physiotherapy … It places ull and unctional movement at the heart o what it means to be healthy. WCPT 1999, p 7
Phys iotherapy diagnos is and ICF In the developmental process o this speci c physiotherapeutic movement paradigm, numerous authors around the globe postulated the necessity o this viewpoint as well as the need or clinicians to
In tro d u c tio n
Subcellular Molecular
Cellular
Tissue
Body part Organ system Body
Person in environment
Person in society External factors Internal factors Individual/environment interface
Micro Macro Continuum of movement
Fig ure 2.1 • Movement continuum theory: suggested model of body of knowledge of physiotherapy. The levels are interdependent: functions of one level in uence movement capacity of other levels. This model should incorporate all concepts of physiotherapy practice. Reproduced with permission from Cott et al. 1995.
make a movement diagnosis as a basis or treatment (Rose 1988, 1989; Sahrmann 1988, 1993, G uccione 1991, G rant 1995, Delitto & Snyder Mackler 1995, H üter Becker 1997, de Vries & Wimmers 1997). Also Maitland, in his early development o the concept, postulated that his work was related to the treatment o ‘movement directions’, which need to be analyzed on their quality, range o motion, motor reactions and pain. The core o the concept was dedicated to the rehabilitation o movement unc tions, overall well being and meaning ul actions (Maitland 1986). The World Con ederation o Physical Therapy takes a clear stance with regard to physiotherapy diagnosis and movement unctions: Diagnosis arises rom the examination and evaluation and represents the outcome o a process o clinical reasoning. This may be expressed in terms o movement dys unction or may encompass categories o impairments, unctional limitations, abilities/ disabilities or syndromes. WCPT 1999, p 7
Inte rna tiona l Cla s s i c a tion of Func tioning, Dis a b ility a nd He a lth (ICF) While the movement continuum theory (Cott et al. 1995) eventually may become the theoretical model which underpins clinical practice and guides research e orts, in daily practice it may not be suitable or making a physiotherapy diagnosis, as the micro levels describe aspects o movement, which cannot be directly observed with the regular clinical exami nation tools o the physiotherapist.
There ore, diagnosis in physiotherapy may be expressed in terms o movement dys unctions using the levels o disability as described in the International Classi cation o Functioning, Disabil ity and H ealth (ICF) (WH O 2001):
• Functions are the physiological or psychological • • • • • • •
unctions o body systems. Body structures are anatomical parts o the body such as organs, limbs and their components. Impairments are problems in unction or structure such as signi cant deviation or loss. Activity is the execution o a task or action by an individual. Participation is involvement in a li e situation. Activity limitations are di culties an individual may have in executing activities. Participation restrictions are problems an individual may experience in involvement in li e situations. Environmental and personal actors make up the physical, social and attitudinal environment in which people live and conduct their lives.
O ne suggestion is to incorporate the ICF in the basic taxonomy o physiotherapy and manual therapy practice (H engeveld 1998, 1999) to allow ollow up o treatment goals beyond impairment levels, as debated by Dekker et al. (1993) and Van Baar et al. (1998ab). The analysis o impairments o movement unc tions has been the speci c domain o manual thera pists or a long time. Figure 2.2 delineates a model in which manual therapists can integrate their 67
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The Maitland Co nc e pt: Evide nc e -bas e d prac tic e and the mo ve me nt s c ie nc e s
Participation – social roles
Individual illness experience (prioritizing treatment goals)
Activities – resources/restrictions Precautions Contraindications
Joint
Muscle functions
Neurodynamic functions
functions
Treament goals
Movement impairments Pathobiological processes Stages of tissue healing
Others: blood vessels, viscera
Soft tissue functions: skin, fascia, connective tissue
Fig ure 2.2 • Model of ICF with the integration of a manual therapy-speci c taxonomy of impairment analysis. Adapted from Hengeveld 1998, 1999 with permission.
speci c taxonomy o analysis o the components o movement impairment into a model o the ICF. This model may urther serve in the de nition o comprehensive treatment goals at all levels o disa blement, in which the individual illness experience (Kleinmann 1988) may determine the priorities o goal setting at each level o disablement. In rehabili tation, the speci c strengths o the di erent pro es sions may be better utilized: or example, generalist physiotherapists and occupational therapists have developed many skills in rehabilitation at the levels o activities and participation, whereas manual ther apists are able to give their special contribution to a team through the analysis and treatment o move ment impairments and pain.
Evide nc e -bas e d prac tic e The physiotherapy pro ession has come a long way since H islop’s historical, groundbreaking lecture in 1975. Many countries have established scienti c communities and a regular exchange o in ormation at con erences, in peer reviewed journals and by electronic means is taking place. As is the case with many other pro essions in the medical eld, physi otherapy has moved into the era o evidence-based practice. Practice guidelines are being developed and recommendations or care are given based on reviews and meta analyses o clinical trials. Evidence based practice has been de ned as ollows (Sackett et al. 1998): 68
The conscientious, explicit and judicious use o current best evidence in making decisions about the care o individual patients. The practice o evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence rom systematic research.
It is emphasized that evidence based medicine is not ‘cook book’ medicine and the clinician needs a mastery o patient interviewing and physical exami nation skills (Sackett et al. 1998, p 2, 3, IX).
Dilemmas and challenges of evidence-bas ed practice Compliance with evidence based practice is highly recommended; however, at times it may put clini cians in a dilemma when making decisions based on the best available external clinical evidence. Part o the dilemma is caused by the act that actors other than selecting treatment procedures play an impor tant role in providing optimal care; urthermore, clinicians might encounter problems, which might not have been put under scienti c scrutiny in such a way as to be accepted as ‘best evidence’ within the value system o a given scienti c and political community. Sackett et al. (1998) and Straus et al. (2005) described di erent levels o evidence, which are, however, in contrast to levels o evidence as described by van Tulder et al. (1999, in Bekkering et al. 2003) (Table 2.1).
Evid e n c e - b a s e d p ra c tic e
Table 2.1 Levels of evidence of different research groups
Level of evidence
Level of evidence
Level of evidence
I
Systematic review
1A 1B 1C
Systematic review/RCTs RCTs with narrow conf dence interval All or none case series
1 strong
Consistent results rom several RCTs o high quality
II
RCT – randomized clinical trial
2A 2B 2C
Systematic review cohort studies Cohort study/low quality RCT Outcomes research
2 moderate
Consistent results rom one RCT o high quality
III
Quasi-experimental studies
3A
3 limited/ contradictory
One RCT or inconsistent results in several RCTs
3B
Systematic review/case-controlled studies Case-controlled study
4 no evidence
No RCTs
IV
Pre-experimental Studies
4
Case series, poor cohort case controlled
V
Expert opinion
5
Expert opinion
VI
‘Hearsay’
Sackett et al. 1998
Sackett et al. 2008
It appears that both listings have been developed rom di erent viewpoints. While van Tulder et al.’s list might help scientists with meta analyses and orms the basis or the development o practice guidelines, Sackett et al.’s list has probably been developed rom a clinician’s point o view. In particu lar, van Tulder et al.’s levels o evidence list might cause clinicians problems in various daily clinical situations because physiotherapists o ten need to make decisions on treatment or problems or which no randomized control trials (RCTs) have been pub lished. For example, the treatment o common prob lems such as osteoarthritis o the carpometacarpal joint with passive mobilizations and muscular control does not appear to have caught the interest o clinical researchers yet. A CINAH L and Medline Database search up to December 2011 reveals that there are no studies investigating this topic, although numer ous studies have dealt with the physiotherapeutic treatment o osteoarthritis o other joints, such as the knee complex or hip (e.g. H oekstra 2004, O ttawa Panel 2005, Dieppe & Lohmander 2005, Moss et al. 2007, Altmann et al. 2010). Similar examples can be given or the treatment o neurodynamics and move ment disorders. A body o knowledge, underpinned by systematic inquiry, is growing, however, to date, only ew systematic reviews have been published (Ellis & H ing 2008). There ore, a list o levels o evidence, which integrates only RCTs may leave
Van Tulder et al. (1999) in Bekkering et al. 2003
physiotherapist clinicians with a sense o discom ort, particularly because they have been integrated into practice guidelines (Bekkering et al. 2003) and there ore may have implications on policies being derived rom them. The emphasis on experimental, quantitative research, RCTs and meta analyses as the highest level o evidence may be use ul rom a somewhat purist scienti c point o view. H owever, sometimes in ormation rom qualitative research or clinical case studies might be more in ormative or clinical deci sion making than a RCT or meta analysis. Clinician physiotherapists may ace various other dilemmas with regard to evidence based practice as, or example:
• In the rehabilitation o pain ul movement disorders, the way that treatment is applied, the communication between the physiotherapist and the patient and aspects such as motivation, belie s, learning experiences, collaboration, education, setting, individual concerns and so on may inf uence the results o the treatments applied (Linton 1998). In decision making processes with regard to treatment subtle non-biomedical cues as intonation o voice, body language, acial expression and selection o words may have a decisive inf uence on the way treatment is being applied (Stein 1991). 69
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This raised the question: i the e ects o a sound therapeutic relationship as a basis or clinical practice have already been researched in such detail that RCTs and meta analyses would be available to underpin current clinical practice? (Linton 1998). • Regardless o available studies, it is more likely that evidence based practice guidelines may at times give an indication as to which decisions not to take, such as, or example, avoiding bed rest and overreliance on X rays, but they may give little indication as to which topics speci cally should be addressed, which may be o concern to the individual patient and which may inf uence the nal outcome o the patient’s problem (Van Tulder et al. 2006, Vleeming et al. 2008). In an analysis o evidence based practice and client centred care, Bensing (2000) raises the question as to how much client centeredness is represented within evidence based practice and how ar evidence based client centred practice has been established to date. She argues that evidence based practice, in spite o its de nition, has become more disease oriented rather than client oriented. In a client centred approach clinicians should base their decisions on the best available evidence and an individual’s needs and pre erences. She postulates that with the development o guidelines, protocols and standards derived rom evidence based medicine, ‘the discussion about norms and values seems to shi t rom the clinician’s consultation room to the con erence room o the pro essional association’ (p. 19), in which there may be no space le t or individual decision making processes by the clinician collaboratively with the client. In this way, individualization o treatment may become restricted and the responsibility or clinical decisions shi ts rom a personal clinician patient decision to a pro essional group decision (Bensing, 2000). In a study with audiotaped interviews and questionnaires with one month ollow up Turner et al. (1998) concluded that providers typically addressed medical issues, but did not assess or inconsistently assessed unctional limitations related to pain and did not discuss how to resume normal activities, although this was a highly rated goal or most patients. Physicians o ten did not adequately reassure patients that serious conditions were 70
ruled out, nor did they consistently address explicit worries by the patient. Foster et al. (2008) support the need to assess patients’ cognitions about their back problem, as they concluded rom their study, using various questionnaires that patients expecting their back problem to last a long time, perceiving serious consequences or holding weak belie s in the controllability o their pain, were more likely to have poor outcomes six months a ter initial consultation. O n the other hand, Moore et al. (2000) point out that illness perceptions, such as pain related worries and ear–avoidance belie s, may be more e ectively treated when sel care about pain and unctional limitations are addressed at an initial consultation and written in ormation material, such as books or videos, is provided. • The inclusion and exclusion criteria or many studies orm another aspect o the dilemma. Physiotherapists may not always recognize their own patients as they are presented in clinical studies: inclusion criteria may be based on pathobiological diagnoses rather than on movement disorders (Malu et al. 2000) or outcome measures used in the studies may not ref ect the relevant clinical outcome measures o pain and movement unction o the physiotherapist (Jones & H iggs 2000). Nevertheless in recent years several classi cations appear to give a more suitable ref ection o the clinical reality o physiotherapists, such as, or example: McKenzie’s (1981) classi cation o pain distribution and a patient’s reactions to repeated movements; Sahrmann’s and O ’Sullivan’s classi cation o movement and motor control (O ’Sullivan 2005), and also the adaptation o O ’Sullivan’s work on movement disorders o the oot and ankle (Kangas et al. 2011). H owever, it appears that no internationally established, validated classi cation system is available yet or physiotherapy speci c research (Billis et al. 2007). • Another dimension o the dilemma may lie in the act, that many o the problems encountered in daily physiotherapy practice are multicomponential and multidimensional movement disorders, whereas many studies deal with problems which are unistructural in nature, in which it is assumed that the
Evid e n c e - b a s e d p ra c tic e
problems have a single cause and need a single treatment approach. • Studies with regard to outcome measurements may not be o the same relevance as outcome measurements in daily clinical practice (Jones & H iggs, 2000). Furthermore, it appears that in every newly built scienti c community similar discussions seem to take place, on or example, the questions o validity, reliability, sensitivity and speci city o clinical assessment procedures. Some scientists seem inclined to recommend discarding tests with low reliability coe cients, or example, palpation procedures and intervertebral mobility tests, without o ering use ul alternatives to assess the parameter concerned (Comeaux et al. 2001, Bullock Saxton et al. 2002). H owever, a more di erentiated analysis o reliability studies and their results show that values may increase i the data are being clustered (DePoy & G itlin 1998), or when re erence standards di erent rom inter therapist comparisons are being employed (Jull & Bogduk 1988, Phillipps and Twomey, 1996). Although it may be use ul to discard examination and treatment methods, which are proven to be ine ective, no relevant procedures should be rejected without o ering meaning ul alternatives. • Whether there is an increasing gap between research based knowledge and its application in clinical practice is debatable. Some authors claim that clinical practice by de nition lags behind science (Van den Ende 2004). H owever, Schön (1983) argues that the experiential knowledge base o clinicians needs to be respected, as clinicians o ten need to interpret incomplete and ambiguous in ormation in order to make decisions with regard to practice. In particular, experiential knowledge with insights or unusual observations rom numerous clinical situations may lead to meaning ul research questions, which over time could be generalized in overall practice (e.g. the application o neurodynamics examination and treatment or passive mobilization treatment under compression o joint sur aces). In such cases clinical practice may be ahead o science. In act, it is noted by Parry that many physiotherapists who contributed to current clinical practice employed orms o qualitative research without explicitly re erring to it:
Current practice owes its diversity and vitality to qualitative observation. … Bobath, Knott, Maitland and others who have contributed in no small amount to the knowledge and practice o physiotherapy went through a process, which is characteristic o ethnography, to develop their concepts and techniques. … observed patients and own handling systematically, constantly analyzing the e ects … keeping a written record, making comparisons with other records, and using insights rom experience to modi y techniques. … In this way physiotherapy can run ahead o science or decades be ore research in the biomedical sciences begins to provide objective supporting evidence. In the interim many innovations will be rejected as well as disseminated according to practitioners’ judgement o their e ectiveness. (Parry 1991, p 437)
In order to allow or uture innovative practice, and not just to scrutinize existing practice, physi otherapy practice needs clinicians with a balanced approach to the application o research ndings and an open mind to clinical presentations which seem at odds with the current actual theoretical models and clinical rameworks. A critical testing o research ndings is needed in daily encounters with patients. This requires precise observational abilities, critical sel ref ective skills, lateral think ing, pro ound assessment and consequent reassess ment procedures, and a re ned and systematic documentation system, which can describe both regular and uncommon clinical observations in su cient detail. H ence the core elements o this concept o NMS physiotherapy are as relevant as decades ago, when Maitland rst described them.
Evidence-bas ed practice and clinical reas oning As a consequence o these dilemmas physiothera pists are requently le t to their own devices when making the best decisions with and or their patients in daily practice. They o ten need a balanced and pragmatic approach towards clinical practice and results rom evidence based practice. Not only will physiotherapists need a mastery o patient interviewing and physical examination skills (Sackett et al. 1998), but they will also need a prof ciency in the application o various treatments, including communication abilities and clinical reasoning skills. 71
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Clinical reasoning may be summarized as ‘wise action’ (Jones 1995), in which physiotherapists endeavour to integrate three areas into their decision making processes: 1. The best o science 2. The best o current therapies with sound assessment procedures and varied treatment strategies 3. The best o the patient–therapist relationship, with a client centred approach with empathy, unconditional regard and genuineness (Rogers 1980), communication, educational strategies and an awareness o the possibilities o a cognitive–behavioural approach to the overall therapeutic process. Nevertheless, evidence based practice is an essen tial skill or enhancing clinical practice; however, it can only be applied success ully with an increased awareness o clinical reasoning processes (Jones & H iggs 2000) and consequent assessment proce dures. H ere evidence based practice correlates with one o the main pillars o this concept o physio therapy: the primacy o clinical evidence (Wells 1996). The application o consequent reassessment procedures allows or ref ection on the decisions made with regard to treatment, be they arriving rom the experiential knowledge base or rom a propositional knowledge base as evidence based research ndings. O nly the clinical results will indicate i the suggestions o the ‘best evidence’ are indeed applicable to the individual patient. In this way, daily clinical practice may be considered level IV or at times level III o Sackett et al.’s Levels o Evidence, as every treatment session may be considered as a clinical case study, provided these are guided by conscious clinical reasoning processes and consequent reassessment procedures. It appears that the unique approach to clinical practice with the principles as worked out by Maitland more than our decades ago still seems applicable at the beginning o the twenty rst century. It may be appropriate to conclude this paragraph with the ollowing quote rom Pro essor Lance Twomey, Vice Chancellor, Pro essor o Physi otherapy, Curtin University o Technology, Perth, Australia: Maitland’s emphasis on very care ul and comprehensive examination leading to the precise application o treatment by movement and ollowed in turn by the 72
assessment o the e ects o that movement on the patient, orms the basis or the modern clinical approach. This is probably as close to the scienti c method as is possible within the clinical practice o physical therapy and serves as a model or other areas o the pro ession. Twomey in Foreword to Refshauge & Gass (1995)
Mo ve me nt s c ie nc e s and paradig ms to mo ve me nt Paradigms to movement Maitland’s ‘brick wall’ model o clinical reasoning serves as a ramework or decision making processes (see Chapter 1). It serves therapists to take di erent viewpoints in the analysis o a person’s (movement) disorder and pain. The brick wall model o clinical reasoning delineates that a con scious distinction needs to be made in the applica tion o biomedical, pathobiological knowledge and physiotherapy speci c insights. It serves physio therapists to dissociate rom biomedical diagnoses, without discarding them, and to ormulate a physio therapeutic, movement oriented diagnosis as a basis or decision making processes with regard to speci c physiotherapeutic treatment. The brick wall model o clinical reasoning laid the oundation or physio therapists to become aware that they should apply di erent paradigms in the problem solving proc esses with a patient. In addition to biomedical and physiotherapeutic paradigms, other models and perspectives may be integrated in the brick wall model o clinical rea soning. It is postulated that physiotherapists or manual therapists use various paradigms (models) in their clinical reasoning processes, which, depend ent upon the clinical relevance o a given situation, may be employed more or less dominantly (Banks & H engeveld 2010). Several o these models appear to be more or less pro oundly scienti cally exam ined and hence contribute more or less to the accepted body o knowledge o the scienti c com munities concerned. H owever, it seems possible that some studies resulting rom less dominant paradigms in a scienti c community may nd less acceptance and may not be regarded as relevant knowledge contributing to the levels o evidence. Figure 2.3 illustrates di erent paradigms in clinical reasoning processes.
M o ve m e n t s c ie n c e s a n d p a ra d ig m s to m o ve m e n t
Theoretical Biomedical, pathobiological diagnostics (ICD) Neurophysiological models Bio-psychosocial models Biomechanical models
‘Evidence-based practice’ – scientific / experimental evidence
Clinical Physiotherapeutic diagnostics (movement functions &dysfunctions) Rehabilitation models (ICF) Cognitive behavioural models
‘Evidence-informed practice’ – clinical evidence
Fig ure 2.3 • Physiotherapists employ different paradigms in their clinical reasoning processes.
Phys iotherapy diagnos is As stated be ore in this chapter the basis o physi otherapy diagnosis stems rom the subjective and physical examination and exploratory treatments (Banks & H engeveld 2010). Passive mobilizations play a central role in physiotherapy diagnosis in many movement disorders – not only or screening with the aim o reproducing the patient’s symptoms emanating rom di erent joints, neural structures or so t tissue areas, but also during exploratory treat ment and reassessment. The latter demonstrates an important principle o this concept o manipulative physiotherapy: di erentiation not only by assessment procedures, but also by treatment. There or in physiotherapy diagnosis the various orms o assessment, as they have been described by Maitland play an essential role. Not only initial assess ments, but also the assessment during and the reas sessments a ter the application o a therapeutic intervention, as well as, at times, retrospective assess ments, need to be applied to con rm the hypotheses, which have been elaborated during the therapeutic process, to come a nal physiotherapy diagnosis. The terms o the International Classi cation o Functioning, Disability and H ealth (ICF – WH O
2001) may serve as a basis in the description o the physiotherapeutic diagnosis (see Fig. 2.4). A comprehensive description o a patient’s condition needs to integrate observations regarding unctional and possible structural impairments, activity and partici pation resources and/ or limitations, the inf uence o biomedical conditions on the levels o unctioning and possible social – psychological contributing actors to the levels o unctioning (Fig. 2.4).
From biomedical models to bio-ps ychos ocial models In the past physiotherapy practice and research has been inf uenced strongly by the biomedical para digm. H istorically, the ounders o the physiother apy pro ession in the nineteenth and twentieth centuries accepted medical hegemony and adopted biomedical, o ten positivist oriented, perspectives in their work to support their pro essional recognition and permission to practice (Barclay 1994, Parry 1997, Welti 1997, Terlouw 2007). H owever, over the past decades the biomedical model has been challenged, both in the elds o medicine as in phys iotherapy. Engel (1977) challenged the biomedical model by arguing that it placed too much emphasis 73
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The Maitland Co nc e pt: Evide nc e -bas e d prac tic e and the mo ve me nt s c ie nc e s ICF 2001 Health condition (disorder/disease)
Function/structure (impairments)
Activities (activity limitation)
Participation (participation restriction)
Contextual factors A. Environmental B. Personal
Fig ure 2.4 • Physiotherapeutic diagnosis needs to encompass all dimensions of the ICF (after WHO 2001). Reproduced with permission from Banks & Hengeveld 2010.
on pathology without consideration o the psycho social impact o illness and disease. H e argued that biomedical models places too much emphasis on explaining illness and disease by deviations in biological processes. The sole application o the biomedical model creates, according to Engel, a dichotomy with organic elements o a disease on the one hand and, on the other, the psychosocial ele ments o human mal unction, which are o ten asso ciated with causal principles such as psychopathology or psychosocial problems. From a bio psychosocial perspective it is sug gested that various actors may contribute to the development and maintenance o disease, pain and disability:
• • • • • •
Biological processes Emotional aspects Cognitive aspects Social actors Cultural actors Behavioural actors.
The role of the b iome d ic a l mod e l In spite o the shi t in paradigm towards bio psychosocial models and to a more speci c physio therapy diagnosis, biomedical thinking still has an important role to play in the clinical reasoning 74
processes o manipulative physiotherapists. This model is o particular value in:
• Establishing precautions, contraindications and • • • •
the limitations o scope o practice. Establishing a medical or orthopaedic diagnosis as an initial point o re erence or manipulative physiotherapy. Medical screening to determine contraindications and precautions to examination and treatment procedures Prognosis making – estimating the natural healing o healing and recuperation. Recognizing speci c clinical patterns as a contributing actor to a patient’s movement disorder, including their consequences or physiotherapeutic examination and treatment as, or example, movement disorders with a basis in a combination o lumbar stenosis and an activated osteoarthritis o the hip or a stable lumbar disc disorder and so on.
In the current era o shi ting towards the integration o psychosocial issues in medical and physiothera peutic diagnostics and possibly overemphasizing these, it is essential not to neglect pathoanatomical lesions as a possible source o pain, discom ort and disabilities (H ancock et al. 2011, Jull & Moore 2012).
M o ve m e n t s c ie n c e s a n d p a ra d ig m s to m o ve m e n t
As a biomedical diagnosis may give a hint as to physiotherapeutic diagnostics, a physiotherapy diag nosis may give indications to biomedical diagnostics. In act, both perspectives on the diagnosis o a per son’s problem may be in many cases complementary. H owever, in order to de ne comprehensive treat ment goals and measures collaboratively with a patient, the speci c physiotherapeutic examination and assessment procedures, as outlined in this concept o manipulative physiotherapy, should not be skipped over.
The role of the b io-p s yc hos oc ia l mod e l Bio psychosocial viewpoints are now central to clini cal reasoning in manipulative physiotherapy, particu larly in determining management approaches, and relate as such to:
• The individual illness experience (Kleinmann 1988) and the individual’s rame o re erence – or the ways in which the individual has learnt to deal with illness and/ or disability. • Communication skills between patient and therapist. Attentive listening and observation o ten given an insight into the world o thoughts, eelings, attitudes, values, earlier experiences and behaviour o the patients with regard to their disorder. • The psychological and socioeconomic variables in the human experience and how they are more likely to contribute to ongoing pain and disability rather than being a cause o them (Kendall et al. 1997). The essential components o the bio psychosocial paradigm are:
• A client centred attitude, with empathy, • •
• •
•
unconditional regard, genuineness (Rogers, 1980). Ability to employ various communication skills. Collaborative goal setting, joint de nition o parameter to monitor treatment results and selection o treatment interventions with, rather than or, the patient. Choosing treatment interventions which are meaning ul to the patient. Explanation, in ormation and educational strategies to enhance patients’ understanding, motivation and con dence to use their body again. Awareness o behavioural changes: as manipulative physiotherapists requently ollow
objectives to change (movement )behaviour, it is important to realize that behaviour will not change overnight. Insights rom cognitive– behavioural therapy and an awareness o the various roles a clinician may play to motivate a person, are help ul in the guidance o a patient in this process o change.
Phenomenological perspective Within a bio psychosocial paradigm a phenomeno logical perspective may play a central role. Within this perspective the viewpoints o Kleinmann (1988) with regard to the individual illness experience and o Antonovsky (1979) with his studies on a salu togenic outlook on health, illness and treatment deserve special attention. The construct o individual illness experience relates to the personal experience o bodily proc esses and the impact o social and cultural inf uences on this experience. The ollowing aspects are empha sized (Kleinmann 1988):
• The illness experience is always culturally shaped and is dependent on what a society regards as appropriate behaviour, on the personal biography o the person, and on psychological processes, meanings and relationships, so that the social world is always linked with the inner experience o eeling ill. • In this experience powers may exist that can either ampli y or reduce su ering and disability including the behaviours o others, such as relatives or clinicians. This notion is supported by Pilowsky (1997), who argues that clinicians need to be aware o the inf uence o their behaviour on the behaviour o the patients they are treating. Furthermore, there is indication that the clinical reasoning o physiotherapists may be di erent, dependent on the culture in which they are active (Cruz et al. 2012), and may accentuate certain behaviours in themselves and their clients. • Every pro essional is trained to translate the illness experience o an individual into theoretical terms o disease and into a pro ession speci c taxonomy and nomenclature. There ore it is essential that patients understand that every clinician may have di erent viewpoints on their individual illness experience, which may serve as a basis or treatment. 75
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• Interpretation o the narratives o this individual experience should be a core task in medical practice. Neglect o the individual account o the personal experience may lead to alienation o the patient rom the caregiver. The perspective o the individual illness experience may be complemented with the salutogenic viewpoints, as delineated by Antonovsky (1979). Based on a critical appraisal o research outcomes, which have a tendency to ocus on pathogenic actors, the intro duction o a salutogenic perspective – which ollows up questions as to why certain people stay healthy in spite o many stressors – has been suggested. Whilst a pathogenic perspective mainly ocuses on causative actors and the prevention o diseases and other disorders, a salutogenic perspective con centrates on questions as to why people stay healthy in spite o the presence o health risk stressors, and which actors help to guide individuals to nd a better sense o health and well being. As stated by Antonovsky (1987), ‘salutogenic actors are not nec essarily the other side o the coin o pathogenic actors’. Based on a study with Second World War concentration camp survivors, Antonovsky noted that a relatively high percentage o participants indicated to be o good physical and emotional health in spite o the many stressors they had had to endure during the years o the war. H e concluded that a ‘sense-o -coherence’ supports a better resil ience to li e stressors. This construct supports the development and maintenance o a sense o health, a sense o purpose and well being. H e postulated that health is not a xed state, but that people move continuously on a continuum between two extremes o ‘dis ease and ease’. In the examination o patients those actors need to be evaluated, which leads to a backward and orward movement on this health– disease continuum. It may be noted that the salu togenic viewpoints are increasingly recognized in health promotion programmes and they are implic itly present in the pro essional description o physi otherapy practice (H engeveld 2006). In particular, the sense o coherence merits atten tion in this process. It contains three core elements:
• C omprehensibility: can the person comprehend the situation in which he nds himsel ? In the case o physiotherapy practice it is essential to know which perceptions patients have about the cause, diagnosis and treatment options or their problem. Essentially, i the patient understands the basic paradigms o 76
physiotherapy practice, movement unctions can support healing processes and may lead to a better sense o well being. • M eaning ulness: can the person nd a sense o meaning in the situation in which he nds himsel ? Physiotherapists need to take time to explore this construct with their patients and to employ di erent strategies to enhance the sense o meaning ulness. These may encompass educational strategies about pain mechanisms and the use o (active/ passive) movement and relaxation as treatment possibilities as well as regular reassessment procedures in sel management strategies to support the development o a sense o success. • M anageability: does the person appear to have resources to meet the stressors o the situation? Physiotherapists need to develop meaning ul sel management strategies, which have to be reassessed regularly in order to contribute to a sense o success and to the meaning ulness o the treatment chosen and manageability o the problem. To summarize, a salutogenic perspective emphasizes various aspects:
• Ref ection on the basic viewpoints on health and disease – which actors may be decisive as to why certain people remain healthy and others get ill in the presence o certain stressors? • A sense o coherence – this appears to be an important actor or success ul coping with stressors and maintaining a sense o health. • H ealth and disease – these should be de ned on two extreme ends o a dynamic continuum. • Following both pathogenic and salutogenic paradigms, in which the caregiver seeks those actors which may lead to a move backwards towards an experience o illness. Furthermore, the caregiver also seeks actors which promote a orward movement towards an experience o health or well being (Antonovsky 1987, Schü el et al. 1998). With special attention to wording the true value o the salutogenic perspective can be recognized in clinical practice, or example, during examina tion, reassessment and treatment procedures. This may guide the patient towards a greater sense o health and well being. Some examples are given in Table 2.2.
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Table 2.2 In a salutogenetic perspective paying special attention to wording is essential
Situation
Pathogenetic orientation
Salutogenetic orientation
Subjective examination: establishing the severity and irritability o a disorder
If it hurts whilst cleaning windows, do you have to stop because of the pain?
Would you be able to continue with cleaning the windows, in spite of the pain you’re feeling?
Subjective examination
Why is it worse in the morning?
Why would you think the afternoon is better than the morning? What would you be able to do to make the morning the same as the afternoon?
Subjective examination: 24-hour behaviour
What are you not able to do anymore because of the pain?
Which activities are still possible in spite of the pain? Which hobbies and activities would you really like to do?
P/E: active tests o e.g. Lx, F, E, Side exion, Rot.
Could you please bend over? Now turn? etc.
I would like to do the following four movements. (short demo) Which one would you prefer?
P/E: neurological conduction testing
I do not nd anything here!
As far as I am concerned, your re exes, muscles and sensation are perfectly in order.
Examination o accessory movements (many movements are sensitive and the patient demonstrates extreme guarding)
Where does it hurt?
If I move you in this area, where would you feel it to be more comfortable and relaxing?
E = extension, F = fexion, Lx = lumbar spine, Rot. = rotation, P/E = physical examination (Banks & Hengeveld 2010)
Both perspectives – Kleinmann’s view on the individual illness experience and Antonovsky’s model o the disease–health continuum – allow or the development o a speci c phenomenological perspective on physiotherapy practice (H engeveld 2003). O n the one hand, physiotherapists need to inves tigate the more pathogenic actors, which lead to a backward movement on the disease–health contin uum, such as, or example, the presence o possible pathobiological processes, the levels o disability, the su ering and distress o a person with regard to the problem and the illness behaviour, which in itsel is the result o physiological, cognitive, emotional and sociocultural elements o the experience. O n the other hand, in treatment planning it may be use ul to ‘think rom the end’ and consider the possible ideal state o movement unctions i all treatment objectives could be achieved. In de ning treatment goals collaboratively with a patient, physiotherapists may consider which aspects are missing in the ‘ideal state’ and are particularly meaning ul or the patient. (Fig. 2.5). These include:
• Which movement impairments should be •
•
•
•
improved i an ideal state could be achieved? Which activities have to improve? Do any activities regarding participation need to be ollowed up? Is the general level o activity in daily li e optimal, too low, or relatively high? I too low, how does one motivate the patient to increase levels o tness and apply a tness programme? I relatively high, is there any relaxation strategy that the patient may employ in daily li e? Is there any disuse o structures by habituated movement patterns in daily li e which need to be addressed? Does the patient seem to trust the movement o his or her body in daily li e? (I not, how can the manipulative physiotherapist guide the patient to the experience?) Does the patient move with an overly increased bodily awareness (and guarding) or does the body seem to be ‘ orgotten’ during meaning ul activities? 77
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Physiotherapy process from a phenomenological perspective
Individual illness, experience, behaviour (Kleinmann 1988)
Experience of health and behaviour (Antonovsky 1979)
• Movement sensitivity, activityintolerance • Impairments, activity limitations, participation restrictions • Illness behaviour (e.g. avoidance, help-seeking) • Suffering, distress • Pathobiological processes
• Symptoms, signs (impairments) • Confidence in use of body, forgetting body • Level of activity, participation (desirable, optimal) • Prevention/prophylactic measures – awareness of ‘use-of-self’ • Control: knowing what to do/ doing if recurrences occur (active coping strategies) – control over well-being
• Is the patient aware o any preventive measures and the way he or she uses the body in daily li e situations? • Does the patient seem to have an adequate sense o control o the pain or well being? I not, what measures should be undertaken? Currently only ew scienti c studies have been undertaken to examine the role o these phenome nological viewpoints o the individual illness experi ence and the role o salutogenesis on physiotherapeutic clinical reasoning and treatment outcomes.
Neurophys iological models The introduction and acceptance o the ‘gate control’ theory in 1965 (Melzack & Wall 1984) appears to have catalyzed a shi t in the research, assessment and treatment o pain, in which the dominant bio medical dualistic paradigm is gradually being replaced by a more holistic bio psychosocial para digm. In the biomedical paradigm, pain was consid ered as a symptom directly related to the extent o bodily damage. Consequently, treatment was based on the normalization or removal o the underlying pathology. In the absence o bodily damage the mind was assumed to be at ault and psychopathology was in erred (Vlaeyen & Crombez 1999). The gate control theory proposed the hypothesis that central nervous system processing was involved 78
Fig ure 2.5 • Within a phenomenological perspective manipulative physiotherapists guide patients on a disease–health continuum, towards a sense of health and well-being with regard to movement functions. This approach guides physiotherapists in a comprehensive planning of treatment objectives.
in the integration o both sensory discriminative and a ective motivational aspects o pain. From a neu rophysiological perspective the gate control theory implied that pain was not only the result o nocicep tive in ormation ascending rom peripheral struc tures, but also that pain could be modulated by descending pathways in the central nervous system. With this theory it has been recognized that pain could be a result o processing in neuronal networks rather than a consequence o tissue damage alone. The implication o this theory was that cognitive, emotional, behavioural, social and cultural dimen sions were identi ed as essential contributing actors to the pain experience o a person. There ore, neurophysiological paradigms serve various purposes: • They serve to develop a broader understanding o the pain experience o the patient. • They aid in the educational and in ormation processes o patients, to enhance better comprehension o pain and the role o movement and other therapeutic orms in the treatment o pain. • They may also provide therapists with explanatory models or (manipulative) physiotherapeutic processes and methods within a bio psychosocial perspective, ranging rom interviewing, physical examination procedures, therapeutic interventions, to communication and educational strategies.
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• They give basic in ormation on human learning processes and motor learning, in particular.
Ne urop hys iologic a l p a in me c ha nis ms It is argued that pain should be ascribed to diverse mechanisms o the nociceptive system in neuronal networks rather than to a single neurophysiological pain mechanism (Cervero & Laird 1991) and to elements o neuroplasticity or learning processes (Loeser & Melzack 1999). It is suggested that the assessment o pain should distinguish between these underlying neurophysiological pain mechanisms (Cervero & Laird 1991). Table 2.3 demonstrates the clinical identi cation and neurophysiological supporting evidence or the main pain mechanisms commonly encountered in neuromusculoskeletal practice. The interventions o a physiotherapist have to be adapted with the incorporation o ,
or example, sel management and/ or educational strategies. It appears that these neurophysiological pain mechanisms have become a relevant hypothesis category on which clinical decisions are being based in physiotherapy practice. A qualitative study at the end o the 1990s concluded that the concep tualization o pain mechanisms and related concepts still seemed to be an implicit process within manipulative physiotherapy practice (H engeveld 2000). H owever, in 2007 in a qualitative study with experienced physiotherapists observing vide otaped treatment sessions and interviews, Smart and Doody (2007) concluded that the selected participants integrated the above mentioned pain mechanisms and related concepts in their clinical reasoning processes. In a three phase Delphi study Smart et al. (2010) established consensus among 103 clinical experts about the clinical criteria by
Table 2.3 Clinical identi cation of the main neurophysiological pain mechanisms
Neurophysiological Neurophysiological pain mechanism background
Clinical presentation
Remarks
Nociceptive mechanisms
Activation o Aδ- and C-f bres by mechanical, chemical or thermal stimuli, activating the primary a erent neuron. Following ‘all-or none’ responses, secondary and tertiary a erent neurons are activated as a result, leading to pain perception (Fields 1988). Numerous areas in midbrain and cortex are involved (Neuromatrix) (Moseley 2003)
Stimulus-response related symptoms. Quality o symptoms may be stabbing, pulling, sharp, dull. Pain and disability in line o natural history o disorder, i.e. normally in the expected time o recuperation pain decreases and ability to move and unction increases
In cases o tissue injury, antidromic activity o C-f bres may contribute to the in ammatory process (‘neurogenic in ammation’) and contribute to a state o hyperalgesia (Fields 1988). However, concurring with the stages o healing this process will be reversed. In act, its main unction appears to lie in the support o healing processes
Peripheral neurogenic mechanisms
May be provoked by changes in blood pressure gradients (Sunderland 1978), abnormal impulse generating sites due to changes in ion channels, trauma such as traction or rubbing (Butler 2000)
Stimulus–response related symptoms. Pain and disability in line o natural history o disorder. May be more severe. Quality burning, throbbing, cramping. May be particularly severe at rest. Symptoms and disability may ollow course o the natural history o the disorder; however, due to the underlying mechanisms this may take more time than dominant nociceptive mechanisms
Treatment f rst may need to be addressed to the tissues surrounding the nerves (inter aces), be ore directing treatment to the nervous system by palpation, ‘slider’ or ‘tensioner’ techniques (Butler 2000, Shacklock 2005, Coppieters & Butler 2008)
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Table 2.3 Clinical identi cation of the main neurophysiological pain mechanisms—cont’d
Neurophysiological Neurophysiological pain mechanism background
Clinical presentation
Remarks
Central nervous system (CNS) modulation
Ongoing sensitized states in dorsal horn, thalamus, cortex. Pathophysiological processes as well as cognitive, emotional and/or behavioural actors may play an important role in ongoing sensitization (Wool 1991, Jeanmonod et al. 1993, Gi ord & Butler 1997)
No clear relationship between pain, disability, natural history o the disorder and movement behaviour. Clinical presentation does not necessarily ollow a clear recognizable clinical pattern
Especially the modulatory in uence o the central nervous system on transmission o nociceptive impulses has received increasing attention in physiotherapy literature, in which it is recommended to view the central nervous system as an integrated cyclical system rather than a simple cause-and-e ect system distinguishing between a erent and e erent aspects o unction (Wright 1999). A sensitized state is a normal phenomenon in injuries but over the course o healing normally the sensitization decreases. However, in some cases due to pathophysiological processes (e.g nerve trauma) or due to cognitive/ emotional/sociocultural/behavioural actors the CNS remains sensitized
Autonomic nervous system mechanisms
The autonomic nervous system is considered a mediator in the patient’s experience o pain. The level o autonomic activity is determined by the level o threat o the pain experience and is expressed in ‘f ght or ight’ stress responses (Selye 1976, Sapolsky 1994)
Pain may be perceived in a more generalized area, limbs may eel swollen, cold and with di erences in sweating reactions
From a clinical perspective, whilst the threat imposed by the pain is still present, the autonomic activity will be maintained until the threat level, whether this is due to physical, psychological or socioeconomic actors, is dealt with
Banks & Hengeveld 2010
which mechanism based classi cation patient pres entations are made. A common denominator in hypotheses generation with regard to nociceptive mechanisms and central nervous system modulation appeared to lie in the relationship between the onset o symptoms and the subsequent reduction o pain and improvement o activity levels with the expected time o tissue regeneration and the perceived sense o control over pain and general well being. In standardized assessments o patients, it has been described that the classi cation accuracy o nociceptive mechanisms and peripheral neuro genic mechanisms is high in patients with low 80
back pain and leg disorders (Smart et al. 2012a, 2012b, 2012c).
End-organ dysfunction and altered nervous system processing – complex clinical reasoning processes The complexity o clinical reasoning processes on multiple, parallel tracks is demonstrated by the neu rophysiological pain mechanisms. O n the one, hand a clinician needs to relate active nociceptive and peripheral neurogenic mechanisms to possible tissue pathology, which needs urther medical action or serves as a speci c precaution or contraindication to
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physiotherapeutic interventions. O n the other hand, the way in which the altered nervous system process ing is inf uencing the pain experience and disability o a person needs to be considered. In particular, at the present time when psychosocial issues receive more attention than be ore (H ancock et al. 2011) and where practice guidelines may become a restrict ing actor in ree clinical reasoning processes (Bensing 2000), it is imperative to consider possible tissue pathology as ‘endorgan dys unction’, which needs to be addressed appropriately. Apkarian and Robinson (2010), there ore, propose ocusing, on the one hand, on an ‘end organ dys unction model’ (EO DM) in which a recogniza ble event led to the development o symptoms and the symptoms coincide with a recognizable presen tation, which can be ascribed to certain tissue or pathobiological processes. In EO DM no altered nervous system processes may be suspected, that is, the pain should decrease and the level o activity should improve over the time o tissue regeneration. Symptoms and signs demonstrate a recognizable, repeatable stimulus response pattern. O n the other hand, i symptoms and signs do not relate to the history or to stimulus response repeatability, altered nervous system processing models (ANSPM) should be considered.
Dyna mic s of a p a in e xp e rie nc e A pain experience and related disability o ten change over time. This can be due to interactions between the individual, his or her environment and medical pro essionals (Delvecchio G ood, et al. 1994) or due to an increasing inf uence o cogni tive, emotional and behavioural actors (Vlaeyen & Crombez 1999), which may include an increas ing sense o distress or su ering, worries, anxiety, a sense o helplessness because o not being able to control the pain or even a sense o worthless ness and impaired sel esteem (Corbin 2003). There ore it can be argued that the interpretation o neurophysiological pain mechanisms may be too linear and that it acknowledges the dynamics o a pain experience insu ciently. As the dynamics o pain start to change over time, the physiothera pist needs to be aware that whereas unctional capacity may improve, the pain experience or the sense o helplessness may not improve correspond ingly and therapeutic interventions should ref ect this common phenomenon. The interventions o a physiotherapist have to be adapted with the
incorporation o , or example, sel management and/ or educational strategies.
Integrative, dynamic models of pain From a neurobiological perspective, integrative models express the dynamics o a pain experience to which the approach to therapy needs to be adapted. Such models include:
• The mature organism model (G i ord 1998) • The processing model (Shacklock 1999). These models try to explain the pain experience rom the perspective that input o noxious stimuli will be processed in the central nervous system, which consequently may inf uence output response o the body to the threat o the noxious stimuli. From a biological point o view, the brain or central nervous system may be seen as a discrimina tion centre that continuously scans the environ ment, one’s own body and relevant past experiences (G i ord 1998). The central nervous system processing may be inf uenced by biological actors, cognitive, emotional aspects, social cultural meanings and previous learn ing experiences. It is suggested that this processing o the central nervous system may be o major inf uence on e erent physiological systems, like muscle tone, autonomic responses, endocrinological and immuno logical systems, as well as on behavioural reactions like expression, movement or activities (‘output mechanisms’). Furthermore, these ‘output mecha nisms’ will inf uence the ‘input’ and the sensitivity to all kinds o stimuli – demonstrating the cyclical nature o ‘input’, ‘central processing’ and ‘output’ mechanisms (G i ord 1998, Shacklock 1999).
De nitions of p a in with re ga rd to inc lus ion c rite ria in re s e a rc h As pain mechanisms appear to become increasingly relevant inclusion criteria to research projects, Bogduk (2009) discusses the necessity o making a clear distinction between nociceptive back pain, somatic re erred pain, radicular pain and radiculopa thy. I radicular pain is not distinguished rom somatic re erred pain, diagnostic errors may occur and patients may be allocated to aulty (sub)groups in scienti c research. (Table 2.4). Bogduk postulates that nociceptive back pain and somatic re erred pain occur more requently than radicular pain and radic ular pain may be investigated with MRI or X ray procedures, while somatic re erred pain o ten gives inconclusive results. 81
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Table 2.4 Distinction between common types of pain (combinations are possible) Description
Cause
Remarks
Nociceptive back pain
Noxious stimuli o lumbar structures
Somatic re erred pain
Noxious stimuli o lumbar structures – no stimulation o lumbar root structures. Explanation: convergence o nociceptive a erent impulse on the secondary a erent neuron
Distinguish this type o symptom rom visceral re erred pain and radicular pain
Normally this type o pain is perceived in those areas, which share segmental innervation. ‘Dull, aching, gnawing’, and at times ‘expanding pressure’. Tends to be f xed in location, di f cult to def ne boundaries o the area – pattern o presentation does not necessarily share dermatomal patterns
Radicular pain
Pain caused by ectopic salvos in dorsal root or spinal ganglion. O ten, but not necessarily always, in conjunction with disc protrusions. In ammation o the nerve is the critical pathophysiological mechanism
A nerve root does not react on compression, unless an in ammation is present. A spinal ganglion, on the other hand, is highly sensitive on compression and reacts with heterospecif c impulse salvos within the whole nerve.
Lancinating pain quality, shocking, electric quality. (the term sciatica should be replaced by radicular pain)
Radiculopathy
Neurological condition with a nerve block
Radiculopathy is not def ned by pain, but by motor and sensory changes
Numbness (dermatomal), weakness, reduced re ex activity
‘Dull, aching pain in back’
Cognitive–behavioural models Physiotherapists play an important role in changing patients’ behaviour, particularly in relation to move ment and unctional capacity. From a phenomeno logical perspective they guide individuals to a sense o well being and health promoting (movement ) behaviour. In this context it is recognized that behaviour and habits may not change overnight, a ter a single instruction session. Part o the work o physiotherapists involves change management, or which motivation, awareness, insight and care ul planning by the patient and therapist are needed. It is necessary to recognize that patients may go through di erent phases o motivation in which they need guidance be ore new behavioural patterns are e ectively incorporated into daily li e. There ore, it may be use ul to incorporate insights rom cognitive–behavioural models into clinical reasoning processes. Cognitive–behavioural practice has a role to play in the application o mobilization and manipulation and more particularly in achieving the desired 82
Type of pain
e ect o maximizing unctional capacity. This may encompass: • Changes in movement behaviour in daily li e – i pain or discom ort occurs, individuals learn to per orm certain movements, relaxation techniques or simple exercises • Changes in habitual patterns o movement in daily li e, which may be a causative actor o pain • Motivation to change behaviour with regard to training and maintaining tness • By means o in ormation and educational strategies patients may develop a di erent perspective on their problem. For example, the meaning o pain as a threat may change; there ore the patient is empowered to develop di erent coping strategies. As well as skilled communication, an awareness o key cognitive–behavioural strategies is important or more e ective clinical practice. These include:
• Phases o change • Role o a physiotherapist as an educator • Compliance enhancement.
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P ha s e s of c ha nge It has been suggested that individuals may go through various phases o motivation be ore they start to change behaviour. It is essential to recognize these phases and to adapt the education and instructions to them. Prochaska and DiClemente (1994) proposed the stages o change model: 1. Pre contemplation: in this phase change o behaviour is not considered. 2. Contemplation: change o behaviour is considered; however, no concrete plan exists. 3. Preparation: plans are developed actively to change behaviour in the short term. 4. Action: phase in which the desired behaviour is per ormed. 5. Consolidation: the desired behaviour is maintained and reversion to previous behaviour is prevented.
The p hys iothe ra p is t a s a n e d uc a tor Increasingly educational strategies to motivate patients to change are being used in physiotherapy treatments and research. The application o educa tional principles, such as the establishment o the cognitive level o the patient and the selection o educational methods and material, are important elements.
Comp lia nc e e nha nc e me nt Various strategies may need to be employed to enhance the patient’s compliance with the phy siotherapist’s suggestions, recommendations and instructions. This may include motivational phases, short term and long term compliance. The phases o change, education and compliance enhancement are discussed in more detail in Chapter 8 o Maitland’s Vertebral Manipulation (H engeveld & Banks 2014).
Re s e a rc h Some studies appear to compare cognitive– behavioural therapeutic approaches with physio therapeutic approaches (Pool et al. 2010); however, it can be challenging to comply with the protocols, as intrapersonal physical and cognitive actors and situational variations determine the prioritization o treatment procedures, including communication and advice (G reen et al. 2008, Sandborgh et al.
2010). O verall it seems that the integration o cognitive–behavioural therapeutic approaches to physiotherapy practice is recommended and there is moderate evidence that they enhance treatment outcomes (Bunzli et al. 2011). It is postulated that cognitive–behavioural concepts, such as dis traction and sel e cacy, are intrinsic to physio therapy practice and need to be explicitly employed in the provision o physical sel help strategies in gaining control over pain (Zusman 2005). An integrated approach o physiotherapy and behavioural medicine implies that cognitions, emotions, physical and social environment are as important as physical prerequisites or movement behaviour (Sundelin 2010). An increasing number o publications regarding the implementation o behavioural principles in physiotherapy practice demonstrated bene cial e ects on disability levels, ear avoidance behaviour, increased pain control and perceived ability to manage uture activities (Moore et al. 2000, Johansson & Lindberg 2001, Söderlund et al. 2001, Åsenlö et al. 2005, Bunzli et al. 2011).
Biomechanical models Biomechanical insights such as the ‘convex–concave rule’ or peripheral joints (Schohmacher 2009) or theories on coupling o spinal movement (White & Panjabi 1978) may also be models that can be utilized in clinical practice. In act, in several schools o manual therapy they have been a pivotal part o decision making processes with regard to treat ment. Current insights, however, demonstrate that that the joint sur aces may move di erently than the theoretical rule would imply (Stenvers 1994, Schohmacher 2009, Vicenzino & Twomey 1993). This should not be used an excuse to dismiss the application o theoretical, biomechanical models to the care o the individual patient, but these models need to be linked to clinical ndings such as, or example, changes in pain and resistance perceived during passive motion. Selection o passive treatment techniques should primarily be based on clinical ndings o changes in pain, resist ance and motor responses during passive accessory and physiological movement. In conclusion, bio mechanical theories can enhance decision making, provided the e ects o every selected technique are regularly reassessed. 83
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Co nc lus io n NMS physiotherapists’ thought processes revolve around various paradigms with the aim o indivi dualizing and optimizing treatment or individual patients. It seems that a moderate to acceptable scienti c knowledge base derived rom these para digms is available to underpin clinical practice. H owever, it appears that several practice guidelines are still based within a biomedical model. In order to guarantee client centred approaches to physio therapeutic treatment in the uture, in this era o evidence based practice, it is suggested that the practitioner acknowledges various paradigms in clinical practice guidelines as elements o the ‘best available evidence’, in particular, the cognitive– behavioural integration into physiotherapy practice, salutogenic approaches as complementary to patho genic approaches and the insights rom neurophysi ological pain mechanisms. The principles o the Maitland Concept o neu romusculoskeletal physiotherapy as outlined some decades ago are still relevant in these times o evidence based practice. Individualized assessment procedures, deliberate treatment planning collabo ratively with the patient, conscious communication strategies with the development o a therapeutic, client centred relationship and a constructive sel critical attitude towards their own clinical decision making processes are the basis or the clinical
approach. I physiotherapists regularly ref ect on their decisions in planning phases o treatment and during reassessment procedures and implement ‘the best o science’ into their work, then they will support their own development towards clinical expertise and may contribute to clinical science by the observation, treatment and reporting o uncom mon clinical phenomena. Individualized treatment needs to be based on thorough clinical assessment procedures, in which the patient’s movement status, movement potential and pre erences are estab lished. Therapeutic touch and the art o passive movement as a kick start to active movement still have a considerable role to play in the rehabilitation o many pain ul movement disorders, as stated by Jull and Moore (2012): H ands on, hands o ? There is ample evidence o changes in motor control in association with neck and back pain. Thus there is no argument that exercise and activity are important components o any rehabilitation program to address these de cits. There is also ample evidence that zygapophysial joints and discs are common sources o pain. Manipulative/ manual therapy is directed towards the pain ul joint dys unction and there is a considerable body o research into the mechanisms o e ect and e ectiveness o manipulative therapy. Manipulative/ manual therapy has proven pain relieving e ects. […] the evidence suggests that the use o manipulative/ manual therapy should not be orgotten. Pain ul joint dys unction is present in the vast majority o neck and low back pain patients … (J ull & Moore 2012, 199)
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Intro duc tio n The temporomandibular joint complex differs from other peripheral joints in the human body in several aspects. Both distal joint partners are part of one bone, the mandible, which makes both joints a Siamese twin joint, the only peripheral one of the neuromusculoskeletal system. This means that one joint cannot move or be moved without the other. Moreover, the jaw joints are parts of other systems as well: the stomatognathic system, part of the digestive tract, the breathing system, and the joint complex play a role in communication 88
and expression. Anatomically, arthrokinematically, neurophysiologically, and therefore in many pathological states, the craniomandibular complex is directly related to the cervical spine. In addition to the joint surfaces, joint contents and muscles, a third entity plays a relevant role in the position and movement of the jaw complex: teeth contact (occlusion and guidance), or the absence of (disclusion), during jaw movements and at rest. O cclusion as a leading entity can be included in Panjabi’s three subsystem model of stability, as referred to in several chapters of this edition. Panjabi’s model provides a useful model for understanding and managing the majority of temporomandibular dysfunctions (TMD) and orofacial pain (O FP). O cclusal aspects may play a role in postural control as well. In modern society, teeth also play an increasing role in human aesthetics and psychosocial issues. Large, beautiful, teeth and an inviting smile are considered important, can increase self-esteem and can be career-supporting. Nowadays, orthodontics is a standard procedure for adolescents in many countries to guide and correct mandibular and teeth growth inconsistencies. The latter are common as the mandible needs to grow to a much greater extent than its adjacent skull bones, the maxilla and the temporal bone, after birth and a variety of factors may interfere with awless development. Beautiful teeth, however, have to follow the functional rules of occlusion and disclusion at rest and guidance at movement as well. In dentistry, occlusal factors are considered to play a relevant role in the
Th e o ry – fu n c tio n a l a n a to m y
Key words Temporomandibular joint, craniomandibular dys function, larynx, hyoid, trigeminal nerve, s pinal nucleus of the trigeminal nerve, chewing mus cles , mas ticatory mus cles , mas s eter, temporalis , lateral pterygoid, medial pterygoid, infrahyoidal mus cles , s uprahyoidal mus cles , occlus ion, parafunctional habit, bruxis m, emotional motor s ys tem, s plint
etiology and management of many dysfunctions and pain. Therefore, the primary discipline involved in analysis and management is likely to be dentistry or orthodontics for most patients. Furthermore, the chewing muscles play a natural role in stress coping. Excessive grinding and clenching of the teeth may lead to abrasia of the anterior teeth, the incisors and canines, as well as to muscle pain. Teeth grinding at night (bruxism) is the most common example of a variety of stress-induced parafunctional habits and bio-psychosocial and neurophysiological factors should be considered in treatment, alongside assessment and management. Finally, women in their reproductive years suffer up to four times more from craniomandibular dysfunctions than men (LeResche et al. 1997, Cairns et al. 2003). There are several accepted explanations for this. There are differences in stress coping between men and women. Female hormonal factors, such as the effects of oestrogen, play a role in pain threshold and intensity before the menopause and women’s chewing muscles have less endurance and less force than those of men. Speci c factors that only affect women should be considered in the management of dysfunctions, for example, changing contraceptives or applying appropriate relaxation modalities. These can be decisive factors in the longterm success of treatment. All of the above indicates that various disciplines can be involved in the management of a single patient. Specialization in these disciplines is required and it is recommended that one provider should be in charge of the coordination of the complex, logistically challenging, long-term multidisciplinary overall management plan. The temporomandibular joint complex is not a regular part of the undergraduate physiotherapy curriculum in many countries. Exploration of basic (neuro)anatomical and arthrokinematical principles in this chapter aims to counter common misconceptions or simpli cations in the management of TMD and O FP as well. Dental nomenclature and dental
medical concepts need to be introduced to enable appropriate understanding of multifactorial, multidimensional dysfunctions, as well as to enable the manipulative physiotherapist to participate effectively in a multidisciplinary setting. Although the role of passive movements in the management of TMD or O FP may be limited, the manipulative physiotherapist can actively contribute in establishing the clinical diagnosis and the formulation and performance of an overall multidisciplinary management plan. Finally, the many disciplines involved in TMD or O FP and the huge amount of available literature account for the ongoing controversies about different areas, ranging from etiology to management. The literature cited in this chapter is a strictly limited selection, but it will enable the reader to explore TMD or O FP in more depth.
The o ry – func tio nal anato my For comprehensive theoretical information the reader should refer to anatomical, biomechanical, dental and orthodontic textbooks (e.g. Ide et al. 1991, Fitzgerald 1992, Kraus 1994, O keson 1985, 1996, 1998). Selected areas are explored in this chapter to give some insight into the most common dysfunctional, pathological conditions. • The fossa of the temporal bone articulates with the mandibular head, which is elliptical and mushroom-shaped. Its cartilage is brous, not hyaline, and undergoes remarkable changes in shape in the course of an arthropathy (Müller et al. 1992ab). • The anterior capsule is attached approximately 4.4 mm (standard deviation 1.7 mm) anteriorly of the eminentia articularis (articular tubercle) (Johansson & Isberg 1991), allowing the mandibular head to move beyond the tubercle. The joint partners are not congruent and movement and position of the mandibular head is aided by the articular disc. The disc is a three-dimensional, biconcave, hat-shaped cartilage structure with thick anterior and posterior parts as well as a thin intermediate part, which divides the joint into two compartments with two different movement tasks. • The posterior border of the disc is aligned on top of or even slightly anterior to the 89
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mandibular head (11 or 12 o’clock position in radiological terms). The physiological position of the mandibular head in the temporal fossa in a closed mouth position with maximum intercuspation (full teeth contact) is de ned by the concept of centric relation (CR): most anterior, most cranial and midway between medial and lateral, with the disc in its correct position (Schimmerl et al. 1993, Bumann & Lotzmann 2000). It is estimated that 85% of the entire population show a different condyle fossa position in habitual occlusion, called centric occlusion (CO ). In dentistry it is a major task to maintain or to restore the centric relation. Note that the normal resting position of the mandible in a closed mouth situation is slightly discluded (upper postural position of the mandible, UPPM), indicating the proprioceptive abilities of the stomatognathic organ (Kraus 1994). • A main function of the lateral pterygoid muscle is to control fossa-disc-condyle stability in rest and during movements. The muscle acts as a ne-tuning, balancing, local stabilizing muscle (O sborn 1995a, Langendoen 2004, Phanachet et al. 2003, 2004). There is experimental two-dimensional evidence that the DA moves passively over the condylus (De Vocht et al. 1996) and that activity of the lateral pterygoid muscle is not required. • In dentistry, the retrodiscal intra-articular area is called bilaminar zone (BZ). It contains synovial uid, the genu vasculosum, a vascular pad acting as an artero-venous shunt during mouth movements and which has signi cant in ammatory potential as well as two ligaments (Schimmerl et al. 1993). • The upper ligament, the Lig. disco-temporale or stratum superius, can be folded and lengthened, enabling translation of the disc-condyle complex in the upper joint compartment. The ligament is anchored in the permeable petro-tympanic ssure, containing bres of the chorda tympani and may be the explanation for a type of tinnitus in temporo-mandibular arthropathies. • The lower ligament, the Lig. disco-condylare or stratum inferior, is non-elastic, remains the same length during movements, thus preventing translation in the lower joint compartment, which is designed for rotation only (Rees 1954, 90
Dauber 1987, Bumann et al. 1991, Eckerdal 1991, Scapino 1991, Rodríguez-Vázquez et al. 1993, Wilkinson & Crowley 1994, Chiarini and G ajisin 2002, Linsen et al. 2006). • Therapeutically, the above implies that anteriorposterior, posterior-anterior and longitudinal cranial accessory movements of the mandible are contraindicated treatment directions in by far the majority of articular TMD cases. • The innervation of the TMJ and the masticatory muscles is supplied by auriculotemporal, masseteric and buccinator end branches of the mandibular branch (NV3 ) of the trigeminal nerve (CN5). The trigeminal nerve complex plays a major role in sensory innervation of almost all craniofacial structures, is connected with several other cranial nerves (facial, vestibulocochlear, glossopharyngeal, vagus nerves) and its relevance is further outlined below (Fig. 3.1).
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Condylus mandibulae Caput mandibulae Discus articularis, Pars anterior Discus articularis, Pars intermedius Discus articularis, Pars posterior Fossa mandibulare ossis temporalis Lower compartment Upper compartment Meatus acusticus externa Eminentia/Tuberculum articularis ossis temporalis Anterior capsule M. pterygoideus lateralis superior M. pterygoideus lateralis inferior Posterior capsule Bilaminar zone/retrodiscal area Lig. disco-temporale/Stratum superius Lig. disco-condylare/Stratum inferius Genu vasculosum/vascular pad
Fig ure 3.1 • Anatomy of the temporomandibular joint.
C a u s e s a n d c o n trib u tin g fa c to rs fo r c ra n io m a n d ib u la r d ys fu n c tio n
Caus e s and c o ntributing fac to rs fo r c ranio mandibular dys func tio n • The ve axial movements of the mandibula are called: ○ depression (mouth opening) ○ elevation (mouth closing) ○ protrusion or protraction (forward shifting of the chin) ○ retrusion or retraction (shifting the chin posteriorly) ○ laterotrusion or lateropulsion (lateral movements to the left and right). • Due to the Siamese twin construction both joints move at the same time, symmetrically or asymmetrically. • Depression, protrusion and laterotrusion are excursive movements as the disc-condyle complex can move beyond the anterior tubercle, whereas the returning movements of the disc-condyle complex into the fossa are named incursive. Although most patients complain of excursive movements, the cause of the dysfunction is often due to a-physiological incursive movement such as a preliminary occlusal contact of two molars. • The functional chewing movement is a threedimensional event with a favourite chewing side and a contralateral balance side. • Arthrokinematically the joint shows at depression: initial rotation of the mandibular head in the lower compartment is gradually followed by anterior translation of the disccondyle complex over the joint surface of the fossa in the upper compartment (Piehslinger et al. 1993, 1994, Ferrario et al. 2005, Mapelli et al. 2009). Limited upper compartment translation is a recognized major etiological factor in the onset and development of an arthropathy. • Increased intra-articular pressure, for example, due to a physiological compression, makes the disc act like a suction cup, inducing a vacuum between its intermediate part and the fossa (Nitzan & Marmary 1997). • Another simultaneous or subsequent factor is a compensatory physiological translation in the lower compartment, commonly occurring in
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cases of underdevelopment of the anteroposterior size of the mandibular head, which negatively extrapolates the fossa-caput discongruence (Müller et al. 1992ab). The latter is one more reason to avoid anterior-posterior or posteroanterior accessory movements, whereas longitudinal caudad distraction, manually, with a continuous distraction splint (for approximately six months) and subsequent dental restoration, seem the appropriate management for most arthropathies (H ugger et al. 2004, Linsen et al. 2006). The mandibular heads’ brous cartilage enables gradual rebuilding from a rounded shape to an anterocaudad slope, induced by pathological translation in the lower compartment. This is considered a major component in arthropathies such as disc instabilities. As the anteroposterior diameter of the mandibular head cannot be in uenced therapeutically, other components, as outlined in Panjabi’s stability model (Panjabi 1992ab) are challenged to compensate. Panjabi’sstability model consists of three interacting subsystems: the passive, the control and the active (Fig. 3.2). The passive subsystem in relation to the temporomandibular complex contains the joint surfaces of the temporal fossa and mandibular head, the anterior and posterior capsule, the extra-, peri- and intra-articular ligaments, the articular disc and all teeth (occlusal component). O cclusal faults such as a lack of molar disclusion in the resting position of the mandible, preliminary molar contact at incursive movements, lack of incisive guidance at anterior as well as lack of canine guidance at lateral movements or a lack of posterior support due to loss of molars (Dulcic et al. 2003) are all considered relevant causal factors for dysfunction and can be dentally managed. Further de cits of the passive subsystem are recognized being relevant factors in TMD, for example: ○ a small anteroposterior diameter of the mandibular head (Müller et al. 1992ab) ○ a deep steep fossa, indicating an increased resistance for excursive movements and muscle activity in the lateral pterygoid muscle (O sborn 1995a) 91
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Passive subsystem Active subsystem Shape of the articular disc (biconcave or planar) Masticatory muscle (maximum and endurance Translatory capacity of the articular disc power) Supra- and infrahyoidal muscles Convexity of the caput mandibulae Mimic, tongue, cervical and Integrity of the lig. disco-temporale, lig. disco-condylare and joint capsule other muscles (larynx, pharynx) Shape of the mandibular fossa Degree of discongruence of fossa-caput centric relation Presence of teeth, occlusal relationships, incisal and canine guidance
Fig ure 3.2 • The three subsystems of stability for the craniomandibular complex (Panjabi 1992ab).
• All this can be compensated within the limits of physiological tolerance by adequate functioning of the other subsystems and remains subclinical. If the limits of structural tolerance are exceeded, for example, by distress factors, the system will decompensate (O keson 1985, 1996, 1998, H ansson et al. 1987). • Distress factors can be categorized within the concept of the control subsystem. The control subsystem for the craniofacial complex contains many parts of the peripheral and central somatic nervous system (SNS) and autonomic nervous system (ANS), such as: • Peripheral course of cranial (primarily trigeminal, facial, glossopharyngeal, vagus, accessory, hypoglossal) and cervical nerves from the cervical plexus and upper cervical posterior rami including autonomic gangliae as well as the sympathetic trunk (Pedulla et al. 2009). • Central nervous system parts with motor nuclei in the brainstem (the truncus cerebri contains pons, mesencephalon, medulla oblongata) and upper cervical myelum, including the nucleus trigeminocervicalis (spinal sensory nuclei of the trigeminal nerve) (Price et al. 1976, Sessle et al. 1976, Bushnell et al. 1984, Kojima 1990, Widenfalk & Wiberg 1990, Fitzgerald 1992, 92
Neuhuber 1998, Imbe et al. 1999, Iwata et al. 1999, G ibson & Zorkun 2008). • The latter receives nociceptive and thermal trigeminal as well as facial, glossopharyngeal and vagal input and its caudad part expands at least to the C3 segment. • Within the spinal trigeminal nucleus, information is represented in an onion skin fashion. The lowest levels of the nucleus, the pars caudalis in the upper cervical cord and lower medulla, represent peripheral areas of the face (scalp, ears and chin). Clinically, this is the most commonly affected area in TMD patients and so it is important to include the upper cervical spine in the assessment and management of TMD (Clark et al. 1987, Browne et al. 1998, Friedman & Weisberg 2000, H uelse M 1998, Reisshauer et al. 2006, Toti et al. 2010). H igher levels in the upper medulla, the pars intermedius, represent more central areas (nose, cheeks, lips). The highest levels in the pons, the pars cranialis, represent the mouth, teeth, and pharyngeal cavity (Figs 3.3 and 3.4). • Trigeminal, facial and vagus motor nuclei are directly in uenced by the limbic system, also known as the Emotional Motor System (EMS) (H olstege et al. 1996; H olstege 2001,
C a u s e s a n d c o n trib u tin g fa c to rs fo r c ra n io m a n d ib u la r d ys fu n c tio n
Nucleus trigeminus
Pons 3
Nucleus trigeminocervicalis Pars cranialis Pars intermedius 2 Pars caudalis C1
1
C2 C3
Fig ure 3.3 • Spinal sensory nuclei of the trigeminal nerve for thermal and nociceptive afferences: nucleus trigeminocervicalis, pars cranialis, intermedius and caudalis.
van der H orst et al. 1997, 2001, G errits et al. 1999, 2004, Mouton et al. 2005). • Distress-induced limbic system activity, for example, resulting from the amygdala, nucleus retroambiguus or the periaqueductal grey) can activate several descending motor pathways causing: ○ mimicking expression ○ vocalization ○ licking, chewing and swallowing ○ and, with an additional hormonal component, lordosis behaviour or receptive posture in females. The latter implies changing tone and activity of abdominal, back, psoas major, adductors and hamstrings during the menstrual cycle. • The EMS offers, in the absence of direct peripheral nervous connections, an explanation for the re ectory Meersseman phenomenon (Esposito & Meersseman 1988, H uelse & Losert-Bruggner 2002, Entrup 2009, Fischer et al. 2009) that malocclusion, limited mandibular depression and limited length of some pelvic muscles correlate. • The EMS is clearly demonstrated by football and hockey coaches during matches. Chewing gum may increase alertness and reduce stress (Tahara et al. 2007, H ellhammer et al. 2009,
3
2
1
Fig ure 3.4 • Representation of facial areas in the nucleus trigeminocervicalis. 1. Pars cranialis: mouth, teeth, pharyngeal cavity. 2. Pars intermedius: nose, cheek. 3. Pars caudalis: scalp, ears, chin.
Scholey et al. 2009, Smith 2010, Johnson et al. 2011) demonstrating that parafunctional habits, to a certain extent, are a useful congenital strategy to cope with stress (Slavicek & Sato 2004). 93
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• Panjabi’s model can be used to address a major question in dentistry ‘H ow much occlusion do we need?’ Whereas persons with positive interactions between the three subsystems can easily deal with a suboptimal occlusion, patients with further dysfunctions (of the passive subsystem: hypermobility, small mandibular condyle, of the control subsystem: excessive parafunctional habits of the active subsystem: weak muscles) need the best possible occlusal relationships (O keson 1985, 1996, 1998, H ansson et al. 1987). The model also con rms the recognized necessity for interdisciplinary cooperation. • Psychological factors, being part of the control subsystem, are generally considered relevant in TMD (Stam et al. 1984, Dworkin et al. 1990, Dworkin & LeResche 1992, Suvinen et al. 1997, Auerbach et al. 2001, Dworkin et al. 2002, Rantala et al. 2003, O hrbach et al. 2010). • Stress coping and management of stress-induced complaints are a common component of the overall management plan and may include splint, cognitive behavioural, pharmacological, body-mind and physical therapy. The role of the physiotherapist in this eld may vary from applying local massage or electrotherapy to relax chewing muscles, individual body-mind therapy such as craniosacral therapy, bio- and myofeedback with breathing procedures, to group therapies with a social character such as yoga, qi gong, or meditation classes. • Relaxing effects on the autonomic nervous system can be monitored with heart rate variability (H RV), a mode to assess the state of the parasympathetic nervous system (Brown & G erbarg 2005, Cysarz & Buessing 2005, Jovanov 2005, Lee et al. 2005, Khattab et al. 2007, Raghuraj & Telles 2008, Li et al. 2009, Schmidt & Carlson 2009, Asher et al. 2010, Patra & Telles 2010, Tang et al. 2009, Matsubara et al. 2011, Nugent et al. 2011). • G ender differences can play a role in all three subsystems and speci c female characteristics need to be considered, for example: ○ passive subsystem: hypermobility, a small mandibular condyle (Müller et al. 1992ab) ○ active subsystem: less muscle endurance power (van Eijden et al. 1995, English & Widmer 2003) 94
○ control subsystem: different stress coping
strategies, hormonal aspects that increase pain sensitivity (LeResche et al. 1997, Cairns et al. 2003) and muscle tension.
Subje c tive e xaminatio n A structured standardized questionnaire and examination such as Research Diagnostic Criteria for Temporomandibular Disorders (RDC/ TMD of the Department of O ral Medicine, O rofacial Pain Research G roup, University of Washington, Seattle USA, Dworkin & LeResche 1992, List & Dworkin 1996, Dworkin et al. 2002) may be advocated for a number of reasons in multidisciplinary clinical or scienti c settings. H owever, the RDC/ TMD questionnaire has recognized limitations in the diagnosis of some articular conditions (Look et al. 2010) and the Maitland model of a semi-structured dialogue is preferred as it enables the clinical physiotherapist to gain in-depth information, to develop various hypotheses simultaneously, and to recognize mixed conditions using sound clinical reasoning.
Kind of dis order Four types of complaints can be considered as leading symptoms for TMD: • Pain just in front of, at or in the ear on mandible (mouth) movements • Sounds just in front of, at or in the ear on mandible (mouth) movements • A blocked mouth opening or closing, all indicating an intra- or periarticular dysfunction • Pain in the masseter and temporal region at mouth opening, chewing or in the early morning, indicating an extra-articular problem A patient with a TMD most commonly has symptoms associated with mandibular movements, such as wider mouth opening, indicating that the source of the TMJ is structural (intra-/ peri-articular or extra-articular). Apart from pain, the main symptom of TMD can be a block, or a clicking sound. In a case where mouth movements and chewingmuscle activities do not seem to relate to the facial or cranial complaints, a primary TMD is less likely and other possible causes, such as dysfunctions of
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Fig ure 3.6 • Typical myogenic or other areas of pain and symptoms in extra-articular temporomandibular joint dysfunctions. Fig ure 3.5 • Typical primary area of symptoms in intra- and periarticular temporomandibular joint disorders.
the upper cervical spine, have to be considered. Pins and needles, numbness of the head, face or tongue and all kinds of other symptoms outside the aforementioned areas (different types of headaches, dizziness, complaints about or dif culties with swallowing, tinnitus, blurred vision and other visual problems, smell, taste or hearing impairments, etc.) can lead to primary cervical spine, neurological, visceral, eye/ ear-nose-throat hypotheses.
Areas of s ymptoms (body chart) • Figure 3.5 shows the commonest pain areas described by patients with an intra- or periarticular TMJ disorder (Campbell et al. 1982). • Figure 3.6 shows common pain sites in patients with extra-articular dysfunctions (Svensson et al. 2003). • Symptoms can include local pain over chewing or hyoidal muscles, radiating pain from trigger points of chewing, hyoidal or cervical muscles, for example, radiating to the teeth, mandible pain after a fracture, etc. • Pain in the jaw can be related to periodontal dysfunctions, tooth decay or infection (odontogenic pain), which may also cause referral of pain locally from the teeth along the jaw. • Aching in the cheeks and jowls could be due to a disorder of the parotid glands. This will be
•
•
•
•
accompanied by changes in function of the salivary glands such as overproduction or dryness of the mouth, even during eating. O ngoing neck pain that is not responding to adequate neuromusculoskeletal treatment may be due to parafunctional habits or occlusal faults and needs dental screening (Clark et al. 1987, 1993, Browne et al. 1998). TMD may be accompanied by tinnitus or may mimic otological disorders such as middle ear infections, which, however, are accompanied by alteration in auditory function and vestibular function (vertigo). The craniofacial area can host many different, bizarre, often called ‘associated symptoms’ that may have a viscero- or neuro-cranium background and may be related to upper cervical and cranial nerves, meninges, cranial bones and osseous connections, parasinuses, auricular or other structures or even neoplasms (Ciancaglini et al. 1994, International H eadache Society 2003, Parker & Chole 1995, Steigerwald et al. 1996, Tuerp 1998, Wright et al. 2000, Lam et al. 2001, Peroz 2001, 2003, Tuz et al. 2003, Sobhy et al. 2004, Wright 2007, Biesinger et al. 2008, 2010, Boesel et al. 2008, Losert-Bruggner 2000). Such symptoms can be pins and needles affecting the head, face or tongue, spasm or trismus of the masticatory muscles, tinnitus, dizziness, vestibular disturbance, tearing, dif culties at swallowing, feeling of a lump in the throat, dystonia, dysfunctions of classic senses (olfaction, audition, vision, gustation, 95
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tactition), nausea, as well as loss of concentration, memory loss, panic attacks and various types of headaches, such as tension type, migraine with or without aura and neuralgic pains (IH S 2003). All these symptoms require speci c neurological screening of the central nervous system, the upper cervical and cranial nerves, as well as radiological and/ or ear, nose and throat (ENT) screening. True trigeminal neuralgia is characterized by severe episodes (attacks) of, often unexpected, burning neuralgic pain, for example, due to arterial compression of the trigeminal nerve (CN5) when leaving the pons or after a herpes zoster virus infection, and is a primary indication for pharmacological or surgical management. The mandibular condyle is a relatively common site of (often) benign tumours. O bvious accompanying signs will be a swollen mass and other signs of impending or actual in ammation. Pain will be relatively constant and unchanging with rest. Symptoms such as pain along the zygomatic arch or the frontal bone accompanied by pressure changes and respiratory dysfunction may well be of sinus origin. Synovial joints also occur between the thyroid cartilage and the sides of the cricoid cartilage, the laminae of the cricoid cartilage and the base of the arytenoid cartilage and occasionally between the lesser and greater cornua in the hyoid bone (Banks & H engeveld 2005). It is not common for these joints to be painful but as they possess synovial joint material and are supported by ligaments, they occasionally give rise to local symptoms.
Behaviour of s ymptoms (over a 24-hour period) • Typical provoking and/ or limited activities in TMD are wider mouth opening when eating, biting, chewing, yawning, singing, kissing, swallowing and prolonged playing of instruments such as the violin, ute or other wind (brass) instruments (Yap et al. 2001). • Parafunctional habits, for example, teeth grinding or clenching (bruxism), inducing 96
• • • •
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•
•
•
•
•
•
muscle pain normally bothers most sufferers in the early morning after sleep or at times of increased distress, whereas occlusal faults may cause muscle pain at (sub)maximal use of the chewing muscle, for example, in biting (Svensson et al. 2008). It is estimated that up to 80% of all TMD patients may suffer this type of myogenic pain (G raber 1989, Bendtsen et al. 1996), which are would primarily be managed by dentists or orthodontist (O mmerborn et al. 2011). Biting on the tongue may be a stress-induced coordination problem. Psychosocial factors should be ruled out by screening (yellow ags). While muscle pain is common, muscle lesions are rare. Chewing and supra- or infrahyoidal muscles may include trigger points with typical patterns of radiation, for example, teeth pain from a medial pterygoid trigger point at biting (Svensson et al. 2003ab, Bertilsson & Strom 1995). Tension-type headaches and muscular neck pain may be accompanied by temporal, masseter or pterygoidal muscle pain. O nly one in eight patients may show a true, isolated arthropathy, with or without clicking; however, they need more often and longer physiotherapeutic treatments than patients with myogenous problems. The remaining 8% of all TMD patients seem to have oro-craniofacial symptoms from other sources such as the cervical spine or the cranial nerves (G raber 1989). Therapists in practices might not see many patients with severe or irritable pain, who are unable to move the mandible and cannot use the mouth at all. The source of intra-articular pain is likely to be in the bilaminar zone, as the retrodiscal area has a large in ammatory capacity. These patients are likely to be managed by the dentist with anti-in ammatory drugs, local cooling and a splint. Clicking sounds are most often a sign of instability of the disc–condyle complex on excursive and or incursive movements. The disc may be anteriorly, anteromedially or anterolaterally displaced in static occlusion or is displaced during excursive movements. The
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2 Click
Click
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Fig ure 3.7 • Temporomandibular joint internal derangement, reciprocal click. (From Kraus 1985. Reproduced with kind permission.)
most classic one, accompanied with a louder click on opening is due to repositioning of the disc on the condyle, whereas the anterior displacement click, terminally at elevation, may not be heard or felt. The clicking on opening may appear initially, intermediate or terminal during opening, representing a further development of the pathology, eventually leading to a non-repositioning situation with the anterior displaced disc limiting full mouth opening (Figs 3.7 and 3.8). • Eminentia clicking is due to poor control at terminal depression or initial elevation and may develop into a block if, when yawning,
• •
•
•
the patient is unable to close the mouth again. A repositioning might need to be performed under general anaesthetic. A lateral ligament clicking or snapping through range of mandibular motion can be palpated super cially with a nger tip on the lateral pole of the condyle. This is normally not painful and may be due to a lateral malposition of the condyle, causing an increased tension in the lateral capsule and ligament. Crepitations are normally signs of degenerative processes, roughing of temporal fossa or 97
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Fig ure 3.8 • Temporomandibular joint internal derangement-closed lock. (From Kraus 1985. Reproduced with kind permission.)
articular disc surfaces, maybe accompanied by morning stiffness of the jaw, however are seldom painful. • O ccasional, almost silent, popping sounds may be caused by sustained compressioninduced brous adhesions between the fossa and disc. • A fracture of thin osseous border with the meatus acusticus externa may cause an over-/ underpressure-induced movement of the remaining capsule at every mandibular movement and so a loud audible snapping noise (Muhl et al. 1987, Westesson & Eriksson 1985, O sborn 1995b, Capurso 1997, 98
Widmalm et al. 1996, 2003ab, Prinz 1998abc, Bumann & Lotzmann 2000, Leader et al. 2003). • These ‘in range-of-motion’ clicking conditions are contraindications for intra-articular directed manual therapy techniques, whereas longitudinal caudad directed techniques to mobilize the capsular structures may be bene cial to deload the intra-articular structures as well. • End-range intra-articular conditions, such as brosis after trauma or surgery, are far less common in daily practice; however, they might pro t from transverse medially directed
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Table 3.1 Examples of TMD categorized according the localization of symptoms in relation to the temporomandibular joint and the degree of the dysfunction
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•
•
•
Source of the symptom and degree of dysfunction
Intra-articular
Periarticular
Extra-articular
Pain problem (severe, irritable) Mandibular movements (almost) not possible
Acute retrodiscal inf ammation in the bilaminar zone, e.g. upper ligament (stratum superius or Lig. disco-temporale)
Acute capsulitis
Tooth pain or tooth extraction pain, mandibular racture, throat inf ammation, trigeminal or acial neuralgia, otitis, chewingmuscle injury, etc.
Through range-o motion (pain) problem
Disc–condyle instability with/without clicking on excursive/incursive movements
Subacute capsulitis or lateral ligament clicking
Spasm (trismus) o chewing muscles, trigeminal or acial neuropathy
End-range (pain) problem
Anterior displaced disc, blocked condylar incursion anteriorly o eminentia articularis (articular tubercle), post-traumatic intraarticular brosis
Chronic capsulitis, limited capsular f exibility, degenerative joint disease
Tightness o the chewing muscles, (upper) cervical spine disorders (including rst rib)
accessory movements at the limit of the problematic excursive movement(s). Active training of the rotatory movement component in the lower joint compartment, however, is generally indicated to support the effect of passive movements (see Fig. 3.55). An extra-articular, muscular dysfunction commonly represents an end-range problem, even to such an extent that it prevents an end-range joint examination, which needs immediate management, if possible (Table 3.1). The laryngeal or hyoid joints and muscles may cause local symptoms such as a feeling of a lump in the throat or a sore throat on swallowing, talking or coughing, which requires medical as well as cervical and psychosocial screening (Pancherz et al. 1986, Winnberg 1987, Winnberg et al. 1988). Acute pain problems are likely to be managed by dental medical disciplines.
His tory of s ymptoms (pres ent and pas t) The onset may have been a trauma, an event or the problem may have occurred completely spontaneously.
Tra uma • Traumatic onsets may have injured, or even fractured, the mandible, the condyle, the bilaminar zone of the TMJ or other skull and neck structures as in motor vehicle accidents, falls with direct impact on the mandible when skiing, biking, being hit at boxing and martial arts or by a hockey stick, being kicked by a horse, or being hit by an elbow, a head or a shoe at soccer (Weinberg & Lapointe 1987, McKay & Christensen 1998, O ’Shaughnessy 1994, G arcia & Arrington 1996, Abd-Ul-Salam et al. 2002). • Even a tooth extraction might become a trauma for the TMJ, with a subsequent in ammation of the bilaminar zone or capsulitis. • A severe retrodiscal in ammation may cause an anterior disc displacement. • Arthroscopy may have been performed to remove a displaced disc. This procedure is not performed routinely, as the disc may resolve in the anterior capsule without causing many problems. • Surgery, in contrast, may be necessary after trauma (fracture) or in the case of neoplasms. • Previous surgery or arthroscopy of the TMJ may demand extensive rehabilitation for 99
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mandibular movements and resting position as well as for the cervical spine.
Eve nts • The onset of the problem might reveal a speci c use category. • Some examples are biting a hard nut, a big apple, a king-size burger, intensive training with (new) musical instruments (jaw muscles, larynx or hyoid region pain), or a period with prolonged and increased distress prior to examinations. • Further common causes are long dental treatment, characterized by maximum mouth opening, an occlusal problem, for example, after dental treatment (new lling), orthodontic management with braces, or other excessive, aberrant use of the mandible. • Even learning a new language might cause transient functional complaints. • Professional singing may lead to complaints at maximum mouth opening, for example, an inability to close the mouth (closing block) when the head of the mandible cannot overcome the tubercle at the beginning of the incursive movement in hypermobile women. • Recognition of the appropriate use category will lead to adequate management and a change in practice. • Recognized distress factors may be the cause of myogenic complaints or even the onset, rather than the cause, of intra-articular complaints. • Bruxism-induced muscle pain may account for 30% of all complaints (G raber 1989). The pain is originally felt at the temporal and/ or masseter area; however, it may spread to the anterior and posterior neck area in later stages. • Local symptomatic treatment is normally insuf cient and long-term success is related to recognition and managing the causal stress factors.
Sp onta ne ous ons e t • The main reason for spontaneous pain in the jaw region is odontogenic and dental treatment will normally be successful. H idden tooth infections, possible causing diffuse general complaints, challenge clinicians and scientists, 10 0
and may only be discovered after a long period of suffering. • Answers to further targetted questions may reveal a hidden cause of the problem. • Analysis of previous trauma, events, psychoemotional and socioeconomic factors as well as further investigations may reveal a range of predisposing factors: ○ an old condylar fracture or juvenile rheumatoid arthritis might have led to a degenerative joint disease ○ a range of congenital abnormalities, maldevelopments of mesodermal structures such as a cleft palate, a suboptimal or absent dental or orthodontic management during the growth years to asymmetrical joints ○ a too small anteroposterior diameter of the condyle to disc-condyle instability ○ a loss of molars to increased joint compression, mainly in elderly people. • O cclusal faults may explain spontaneous symptoms of myogenic origin that are estimated to account for 50% of all complaints (G raber 1989). • Dysfunctions of the anterior upper cervical spine offer another regular explanation for facial pain. • Postural faults, such as an exaggerated thoracic kyphosis with exion of the lower cervical spine, lead to a compensation in the upper cervical spine into extension (poking chin), a posterior change of the upper postural resting position of the mandible and habitual occlusion (bite) (Fink et al. 2003, Klemm 2009, Mansilla-Ferragut et al. 2009, Matheus et al. 2009, Munhoz & Marques 2009, Saito et al. 2009, Schupp et al. 2009, Toti et al. 2010). • A posterior shift of the mandibular condyle challenges the physiological centric relation and may induce intra-articular compensation and hyperactivity of the chewing muscles. • In the absence of any predisposing factor, diseases such as benign neoplasms, gland and lymphatic disorders should be taken into consideration, as well as mandibular and tooth growth anomalies in children (Egermark et al. 2003, Tecco et al. 2010, Thilander et al. 2002).
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Gra d ua l ons e t
Me d ic a l s c re e ning q ue s tions
• Establishing the patient’s history will help towards the diagnosis and the assessment of the stability of the disorder. • The brous type of cartilage of the mandibular head allows a long slow development of degeneration without complaints. After the onset of arthrogenic problems, however, imaging procedures will show a progressed stage of the pathology and recovery might take a long time or fail. • Many patients with a long history report different types of management that have not been completely successful. • O ngoing complaints affecting the facial area may have a large impact on daily life and psychoemotional state. • Persisting impairments and related sensitization of the central nervous system with secondary hyperalgesia and allodynia may lead to the condition becoming chronic, with spreading or bizarre pain patterns and descriptions, accompanied by other psychosomatic symptoms that may overshadow the somatic and still relevant dysfunctions.
• The patient’s answers to routine questions about their general health, other medical problems, use of medication and unexplained weight loss may suggest non-neuromusculoskeletal disorders, serious pathology or relevant comorbid factors that require further examination a change in management or caution. • Women might suffer more frequent and stronger pain due to oestrogen and may need to be referred to a gynaecologist. Speci c medication or a change of the type of contraceptive pill might be indicated. • Imaging procedures are considered important ancillary tools for precise diagnosis. An (ortho) pantomogram is an X-ray procedure performed by the dentist or orthodontist, mainly for dental diagnostics, however, it also shows both TMJ and the atlas-axis relation. • In the case of suspected intra-articular temporomandibular disorder, functional magnetic resonance imaging (MRI) in a closed mouth and open mouth position is a mandatory examination. Further mandibular positions might be examined, for example, while the patient is wearing the splint. • Functional MRI reveals the physiological or pathological position of the disc, an instability of the articular disc, the precise direction of displacement, repositioning of the disc, or lack of, the degree of compensatory or degenerative changes of the head of the mandible, additional in ammatory signs, and also muscular or other anomalies (Schmid et al. 1992, Pressman et al. 1992, Schimmerl et al. 1993, de Laat et al. 1993, Langendoen-Sertel & Volle 1997, Mueller-Leisse et al. 1997, Yang et al. 2002, G uler et al. 2003, Rocha CrusoéRebello et al. 2003, Kitai et al. 2004, Pedulla et al. 2009). • Re-examination after a six-month continuous distraction splint therapy usually shows a stable distraction, indicating the newly formed connective tissue in the distraction-induced joint space. • Special attention should be given to splints that patients may or should wear on the upper or lower dental arch (Bumann & Lotzmann 2000, Tuerp et al. 2004, Al-Ani et al. 2005).
Contrib uting fa c tors • A psychosomatic origin (parafunctional habits causing myogenic pain) as well as psychoemotional consequences of ongoing complaints justify psychosomatic management approaches such as pain management strategies (coping, pacing, graded exposure), cognitive– behavioural therapy, bio- or myofeedback or mind-body therapies, for example, craniosacral therapy, as part of the overall management. • Cranium techniques can be applied in different ways depending on the present state of the patient and the actual aim of the therapy (Ridley 2006). • With structure-directed treatment, cranium techniques may be applied end range, whereas emotional states might pro t from very gentle, slow rhythm handling, inducing balancing effects on the autonomous nervous system, measurable with heart-rate variability (H RV) and the emotional motor system, for example, measurable with EMG of the chewing muscles (see the section on Management).
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• The main types of splints are: 1. Relaxation type o splint (‘Michigan’) or other devices with the same aim, such as an anterior bite stop or a nociceptive trigeminal inhibition tension suppression system (NTI-tss) (Stohler & Ash 1986, Canay et al. 1998, Becker et al. 1999, Baad-H ansen et al. 2007, Macedo et al. 2007, Kares 2008). The splint is worn during sleep with the aim of reducing grinding, thus protecting teeth against abrasia by optimizing occlusion as well as frontal and canine teeth guidance. Patients report that jaw muscle pain, as well as (tension type) headaches and neck pain are positively in uenced. In extreme cases (bruxomania), this type of splint may be worn during the day as well. 2. Repositioning splint. O nly indicated in acute disc displacements with an intact morphology of the disc and the retrodiscal ligaments. To be worn to induce a stable repositioning of the disc and in combination with antiin ammatory drugs. 3. Distraction (or decompression) splint. Indicated in intra-articular disorders, however mainly used in disc displacements with pain, to continuously distract the head of the mandible (six months, 24 hours a day), enabling the formation of hard connective tissue in the joint space that serves as a substitute disc (H ugger et al. 2004). 4. Centric relation splint. This aims to optimize the centric relation, reducing bilaminar and periarticular loading (Tuerp et al. 2004). This type can be used in articular conditions when a distraction splint is rejected by a patient. • Splints normally have a built-in frontal and canine teeth guidance to optimize the quality of the mandibular movement and prevent adverse tissue loading (Fitins & Sheikholeslam 1993). • Special questions and speci c examination procedures for upper cervical risk factors are described in Chapter 4 of M aitland’s Vertebral M anipulation (Blake & Beames 2013). • If the patient has not been referred by a dentist, a consultation is recommended for occlusal screening and, if necessary, management (Egermark et al. 2003, Suvinen & Kemppainen 2007, Tecco et al. 2010). 10 2
Phys ic al e xaminatio n After having summarized the initial hypotheses, the physical examination is planned accordingly. The following section describes a general owchart that is appropriate for the majority of outpatients with a dominant peripheral nociceptive type of problem, who do not demonstrate an acute, severe or irritable problem, or a chronic pain problem with dominant central nervous system processing mechanisms. For examination of cervical and thoracic structures, see Maitland et al. 2005 and Chapter 4 of this volume for examination of shoulder girdle structures. Examination of the upper cervical spine should always be included in an initial craniomandibular examination (Box 3.1).
Pres ent pain? Note area and intensity.
Obs ervation In s ta nd ing G eneral inspection of thoracic, cervical spine and shoulder girdle.
In s itting • • • •
Colour changes Scars Atrophy Swelling/ hypertrophy, for example, convexity of masseter area (Fig. 3.9) • Facial asymmetries.
En fa c e • Any obvious skull or mandibular developmental abnormalities, for example, open mouth/ lips and/ or discluded/ occluded resting position of the mandible (also, ask the patient about the resting position of the tongue). • Note nasal or mouth breathing. • H orizontal alignment of the eyes, zygomatic arches, auricular tragus or ear lobe and mouth. • Symmetry in vertical dimension of the lateral canthus of the eye – corner of the mouth.
P h ys ic a l e xa m in a tio n
Box 3.1 The physical examination of the craniomandibular region Ob s e rva tion
•
• •
•
•
In s tanding: general pos tural obervation In s itting and or s upine lying: vis cerocranium, extraoral Later in s upine lying: intraoral ins pection for occlus al relations hips , periodontological changes , preceding intraoral palpation and acces s ory movements
Pelvis /hip (mus cles ) in combination with occlus ion (Rx1 or 2) Thoracic s pine, s houlder girdle (Rx2 or 3)
Neurodynamic tes ting For s pinal canal, upper cervical and cranial nerves in s itting or s upine lying
Palpation
Functional demons tration
Extraorally: TMJ , s tomatognathic mus cles , nerve palpation s ites
•
Acces s ory movements
•
Their demons tration of their functional movements affected by their dis order Clinical differentiation of their demons trated functional movements
Brie f a p p ra is a l Active mandibular movements and initial palpation in s itting
Active movements • • •
Move to pain or move to limit, if appropriate with overpres s ure in s upine lying Depres s ion, elevation, protraction, retraction, lateral movement left and right Note pain, quantity and quality, including occlus al contacts , incis al and canine guidance
Is ometric tes ts
•
In s upine lying in an appropriate s tarting pos ition of the mandible and including reas s es s ment • TMJ , extraorally: trans vers e medially Preceded by: • • • • • • • • •
Obs ervation (periodontological and occlus al) Palpation (mas s eter and pterygoid mus cles ) Intra-orally: Longitudinal caudally Pos teroanterior Anteropos terior Trans vers e medially Trans vers e laterally Longitudinal cranially Longitudinal dors o-ceph
Stomatognathic mus cles in s upine lying
Palpation and acces s ory movements of the cervical s pine
Neurological examination
• •
Upper cervical and cranial nerves or other precautions if indicated
Cervical s pine (Rx1 or 2) Hyoid, cricothyroid joint, vis cero- and neurocranium in s upine (Rx2 or 3) Order of tes ts may vary
Othe r s truc ture s in p la n
Check cas e records , etc.
• •
Highlight m ain f ndings with asterisks Ins tructions to patient
Actively and pas s ive phys iologically Cervical s pine (commonly at Rx1)
• O verbite or loss of vertical dimensions can be assessed by comparing the distances between the lateral canthus of the eye and the corner of the mouth. • With the anterior nasal spine and the point of the chin (Trott 1986, Kraus 1994). These two distances are normally equal but overbite is present if the second measurement is more than one centimetre less than the rst.
• Anterior neck with hyoid bone and larynx cartilages (including the cricothyroid joint).
In p ro le (Fig. 3.10) • • • •
Concave (prognathic) Convex (retrognathic, for example, overbite) or Straight (orthognatic) facial alignment Assess in relation to cervical posture (poked chin?) 10 3
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B
A
Fig ure 3.9 • Convexity of cheek: A indicating masseter hypertrophy due to parafunctional habit (bruxism) or B occlusal fault. (Reproduced with the permission of the Interdisciplinary Forum for Cranio-Facial Syndromes (IFCFS).)
A
B
Fig ure 3.10 • Facial convexity due to retrognathy: A relaxed with open mouth (habitual) and B with forced corrected closed mouth. (Reproduced with the permission of the IFCFS.)
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Functional demons tration • If pain around the TMJ is reproduced during eating with upper cervical extension and mandibular depression (Fig. 3.11): ○ stabilize the head at the onset of pain and increase or decrease the mandibular depression ○ stabilize the mandible at the onset of pain and decrease and increase upper cervical extension. • If pain is felt at waking up prone with the head rotated (Fig. 3.12), does the contraction of the chewing muscles produce pain in the temporal or masseteric area? Is palpation of muscular sites painful? • TMJ, ear, atlas area: ○ stabilize the head at the ‘bite’ of pain and increase or decrease the lateral deviation of the mandible in the appropriate direction ○ stabilize the mandible in depression/ lateral position and increase or decrease the cervical spine
Fig ure 3.11 • Differentiating between the upper cervical spine (extension) and TMJ (depression) of pain in an eating position.
○ apply temporomandibular and upper cervical
accessory movements (for example,unilateral posteroanterior) in the rotated position for further con rmation. • If throat pain is reproduced during extension of the head, stabilize the head at the point of onset of the symptoms and ask the patient to swallow or move the position of the tongue to differentiate between the laryngeal and hyoid joints and the anterior cervical intervertebral structures. • Check for the correct position of the tongue at the hard palate when swallowing.
Brief apprais al In s itting • O bserve the habitual occlusion. • O pening the mouth as widely as possible while monitoring cervical movement. • Clenching the teeth tightly.
Fig ure 3.12 • Differentiating between upper cervical spine (rotation) and TMJ (depression, lateral movement) in prone lying with rotated head.
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• Move the mandible maximally to the left and right (Fig. 3.13). • Palpation of the chewing muscles.
Ac tive move me nts • In supine lying, with bilateral condylar palpation and sight of the incisal and canine teeth. • The therapist sits beyond the patient’s head facing the patient’s feet. • The patient has to open his lips actively at all times during testing. • Assess pain, quantity and quality such as clicking sounds, incisal and canine guidance, de ective occlusal contact, note and differentiate deviations or de ections.
• Apply overpressure if appropriate, with stabilization of the cervical spine. • Note the effects of head on neck, neck on neck and neck on trunk position on ranges of TMJ movement, pain response and clicking (Lee et al. 1995, de Wijer et al. 1996abc, Palazzi et al. 1996, H igbie et al. 1999, Ioi et al. 2008). • The examination movements may be applicable as treatment techniques in selected cases.
Mouth op e ning (d e p re s s ion) (Figs. 3.14 and 3.15) • Pain: where and when (in mm)? Related to clicking? No pain: apply overpressure by applying a ‘money-counting’ kind of movement with the thumb and index nger. The tip of the
Fig ure 3.13 • Brief appraisal of lateral movement to the left and right in sitting. Lateral movement to the right shows a malocclusion-related compensatory cervical tilt. (Reproduced with the permission of the IFCFS.)
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thumb should push the upper incisal teeth upwards and the tip of the index nger should push the lower incisal teeth caudally. The other hand is placed behind the occiput and cervical spine with the anterior side of the shoulder on the frontal bone to stabilize the head and the neck. • Range: measure in mm including vertical overbite (normally 4 mm), normally 40–55 mm or the width of three ngers (index, middle and
ring nger) at the proximal interphalangeal joints (PIP). • Is there limitation in range with pain in a chewing muscular area? Treat immediately with local massage, hold-relax techniques, electromassage or taping to relax the tensed muscle (Figs 3.16 and 3.17). • Course: symmetrical condylar movement? De exion or deviation, with clicking? Initial, intermediate, terminal clicking?
Fig ure 3.15 • Overpressure for mouth opening with thumb and index ngers at the front teeth. Fig ure 3.14 • Active mouth opening with bilateral condylar palpation and observation of the mandibular course of the movement.
Fig ure 3.16 • Hold-relax technique, biting, with transverse application of spatulas to relax masticatory muscles and gain range of motion.
Fig ure 3.17 • Intraoral massage technique with thumb (intraorally) and index or middle nger (extraorally) to treat localized masseter tightness.
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• Clinical differentiation of clicking in cases of a suspected anterior disc displacement (ADD) with an unstable excursive repositioning, which shows a deviation with clicking initial or intermediate excursively, with or without pain. • Clinical differentiation: depression with a sustained longitudinal cephalad pressure (dynamic compression), which is likely to create more resistance for repositioning and causes a later or louder clicking (more pain?) (Fig. 3.18).
Fig ure 3.18 • Mouth opening with sustained bilateral longitudinal cephalad pressure at the angle of the mandible (dynamic compression) for clinical differentiation of a clicking phenomenon.
• If this con rms an ADD, then perform the differentiation – apply medial pressure (dynamic medial translation) during depression, which is likely to ease repositioning and make the clicking is less loud or absent (Fig. 3.19). • Differentiation. Positioning cotton rolls between the posterior molars prevents terminal incursive movement and disc displacement. Absence of clicking on subsequent depression movements con rms the hypothesis (Fig. 3.20).
Fig ure 3.19 • Mouth opening with sustained transverse medial pressure at the mandible for the right TMJ (dynamic translation) for clinical differentiation of a clicking phenomenon.
Fig ure 3.20 • Preventing terminal mouth closing with bilateral cotton rolls between the molars.
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Mouth c los ing (e le va tion) (Fig. 3.21) • First, an upward movement of the mandible is performed up to the initial contact. • Is there full simultaneous occlusion or a premature, de ective occlusal contact? • Maximum clenching (simulating ‘ ‘overpressure’ as well) towards maximum intercuspation might be accompanied by a palpable and visible mandibular shift or clicking with occlusal faults. • Palpable, respectively with a stethoscope, audible clicking, con rms the suspicion of terminal incursive anterior disc displacement.
P rotra c tion • Pain: assess the site of pain and the range in mm. • In absence of pain, apply overpressure by pushing both angles of the mandible forward with the middle and ring ngers of both hands, while keeping the thumbs at the zygomatic bone to stabilize the head (Fig. 3.22). • In case this causes a lot of pressure pain, pull the mandible forwards with the thumb at the oral side of the mandibular incisives, while stabilizing the head as in depression (Fig. 3.23). • Range: approximately 8 mm, including 3–4 mm horizontal overbite.
• Course: look for incisal guidance with disclusion in praemolar and molar area (Fig. 3.24). • In severe open bites or worn-down incisives this forward teeth guidance is absent and needs to be restored. Look for de ective occlusal contacts. • A deviation with clicking or de exion might show a similar pattern to depression.
Re tra c tion • A small movement (1–4 mm) should be visible and palpable. • No movement indicates a pathological posterior position of the condyle in the fossa. • In absence of pain, overpressure, which compresses the bilaminar zone, is performed with the web space grip around the chin, while stabilizing the neck and the head as in depression (Fig. 3.25). • Lateral movement (lateropulsion or laterotrusion) left and right. • Ipsilateral movement pattern: a linear condylar movement (Bennett shift). • Contralateral movement pattern: an angular condylar movement (Bennett angle). • Assess the site of pain and measure the range of occurrence.
Fig ure 3.21 • Mouth closing with maximum clenching and bilateral condylar palpation. 10 9
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Fig ure 3.22 • Application of overpressure for protraction at the angle of the mandible with middle and ring ngers on both sides and xation with the thumb at the zygomatic bone.
Fig ure 3.24 • Physiological incisal guidance at protraction showing premolar and molar disclusion. (Reproduced with the permission of the IFCFS.)
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Fig ure 3.23 • Application of overpressure for protraction by pulling the mandibular incisives forward with one thumb and xation of head and neck with the other hand.
Fig ure 3.25 • Application of overpressure for retraction by pushing the mandible backwards with the web space of the hand and xation of head and neck with the other hand.
P h ys ic a l e xa m in a tio n
• In absence of pain, overpressure is applied with the ulnar border of the hand, which is metacarpo-phalangeally exed 90°, on the corpus and ramus of the mandible. • The other hand holds the head and neck in place, with the thumb on the zygomatic bone (Fig. 3.26).
Fig ure 3.26 • Application of overpressure for lateral movement to the left with a exed ulnar border of the hand at the right mandible and head and neck xation with the other hand.
• Course: look for physiological canine guidance, or compensatory incisal guidance, assess the site of lacking (prae)molar disclusion respectively (Figs 3.27 and 3.28). • Range: normally approximately one quarter of depression (Figs 3.29 and 3.30).
Fig ure 3.27 • Physiological canine guidance at lateral movement to the right and complete ipsi- and contralateral disclusion. (Reproduced with the permission of the IFCFS.)
Protr 5-8mm
Lat 10-15mm
Fig ure 3.28 • Absent canine guidance on lateral movement to the right due to de ective occlusal contact between left molars. (Reproduced with the permission of the IFCFS.) Depr 36-55mm
Fig ure 3.29 • Visual range of motion scale with normal ranges of movement. (Reproduced from Curl 1992).
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Protr 7mm
Lat 12mm
Clicking 25mm
Depr 38mm
Fig ure 3.30 • Graphic representation of active mandibular movements in a patient with an anterior disc displacement and an unstable excursive repositioning. (Reproduced with the permission of the IFCFS.)
Fig ure 3.31 • Asymmetrical starting position of upper and lower midline for lateral movements. (Reproduced with the permission of the IFCFS.)
• Consider a midline asymmetry of the lower and upper teeth at measuring (Fig. 3.31).
Is o me tric te s ts In s upine lying • Aim: to reproduce muscular pain. • No pain indicates that there is no muscular lesion. 112
• H owever, muscle soreness or tightness due to bruxism or other parafunctional activities may not react with pain on contraction. • Therefore, muscular palpation of sore muscles is considered relevant for diagnosis. • Resistance is applied in a loose-pack position of approximately 2 cm mouth opening with a ‘V’ grip for depression and elevation, while the other hand and shoulder are stabilizing the cervical spine and frontal head respectively (Fig. 3.32). • Further tests are indicated only in cases of pain provocation.
P re c a u tio n s
as motor de cits or sensory loss, numbness, pins and needles (head, face, tongue) and should include examination of the classic senses by a neurologist. • Further precautions may include testing of upper cervical stability and cervical arteries (Blake & Beames 2013).
Neurodynamic tes ts Ce rvic a l s lump a nd oc c ip ita l ne rve ma jor te s t (Ma itla nd e t a l 2005) Fig ure 3.32 • Isometric testing with a web space ‘V’-grip around the chin and a stabilized head and neck.
• In cheek pain, differentiation between the masseter and medial pterygoid muscle is performed by giving resistance against ipsi- and contralateral movement. • Ipsilateral resistance challenges the masseter more and contralateral resistance is more challenging for the medial pterygoid. • In preauricular pain, differentiation between the lateral pterygoid muscle and joint pain may be performed with resistance against protruding contralateral lateral movement or with the PNF technique ‘rhythmic stabilization’ during a chewing-act position, which could provoke a typical cramp reaction of the muscle.
Active tes ts of the cervical s pine To prevent loading of the TMJ, different grips are advocated when applying overpressure. • Upper cervical f exion and upper cervical quadrant: Place the web space of the hand on the maxilla instead of around the chin. • Extension: Place the web space of the hand at the occiput instead of around the chin.
Pre c autio ns Neurological examination • Indicated for the peripheral (cervical plexus, cranial nerves) and central nervous systems in the case of present neurological symptoms, such
• The trigeminal and facial nerves may be involved in facial pain and need to be assessed on pain and range of motion. • An initial neurodynamic differentiation can be incorporated in the functional demonstration. The painful position is stabilized while the effect of additional slump-test components from cephalad to caudad is monitored. • For example, a male person demonstrates mandibular pain while shaving the right caudad side of the chin in the morning, standing exed in the bathroom in front of the mirror facing himself with his cervical spine in upper cervical extension, rotation and side exion to the left, the mandible in lateral position to the left and slightly depressed. This position can be established in sitting on the plinth. • Mandibular as well as upper cervical movement change the pain. Keep the mandible and neck xed and add thoracic exion, then lumbar exion and nally, if possible, a both-sided straight-leg raise to assess changes in the mandibular pain response and to clinically con rm a mandibular nerve involvement.
Ma nd ib ula r ne rve , right s id e • Standardized tests for cranial nerves have been described (von Piekartz 2006). • The patient lies supine with the head over the edge of the plinth supported by the therapist’s abdomen or with his head on the plinth, with 1.5 cm depression and the tongue relaxed. • The therapist stands beyond the patient’s head facing the patient’s feet, grasps the occiput with both hands, with thumbs at the side of the skull, pointing anteriorly. 113
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• The upper cervical spine is then exed, laterally exed to the left and rotated to the left. • The therapist shifts his right hand forward and applies a lateral mandibular movement to the left.
• If intraoral procedures take a longe time, for example, when applying viscero-cranium treatment techniques, it is appropriate to remove the ngers now and then to let the patient relax, swallow or drink some water.
Fa c ia l ne rve , right s id e
Extrao ral palpatio n
• The patient lies supine with his head at the edge of the plinth. • The therapist sits behind the head and let his forearms rest on the plinth. • Upper cervical exion, contralateral side exion and ipsilateral rotation are performed with an ipsilateral grip at the frontal bone and mandible, while the contralateral hand is at the contralateral occiput. • Different parts of the facial nerve can be loaded additionally, for example: ○ a neurocranium manipulation of the temporal bone for the most superior branches ○ depression and contralateral movement of the mandible for the buccal nerve ○ laterocaudad movement of the hyoid bone for inferior branches as well as ○ additional facial muscle contractions. • In this way the mechanosensitivity of the right mandibular branch of the trigeminal nerve and the facial nerve can be assessed and compared with the left side, which can be further con rmed by palpation of super cial branches of trigeminal and facial nerves. • O bservation, palpation and accessory movements can be performed extra- as well as intraorally. For intraoral examination and treatment by a physiotherapist, the patient has to give informed consent in many countries. The therapist may enter the oral cavity with one thumb, one index nger, one little nger, or an index and a middle nger, and needs to wear a medical glove. As patients might have an allergic reaction to latex, vinyl gloves are recommended. In this way, intraoral observation, palpation and accessory movements can be performed more easily at the same time. • The patient’s gag re ex may be stimulated. The therapist must allow the patient to overcome this before proceeding. 114
Palpation of the TMJ • The joint line is located directly anterior to the external auditory meatus and can be palpated from within the ear or laterally just in front of the ear. • The posterior joint tissue is likely to be most tender and swollen and thickened. • Assess the symmetry of both lateral condylar poles in relation to the temporale bone. • Palpation of the super cial branches of the trigeminal and facial nerves aims to con rm neurogenic components of the dysfunction. • Increased sensitivity may have a peripheral cause (compression site); however, with long-standing dysfunctions it is more common that tender neural sites are re ecting central sensitization, see Table 3.2.
Extra- and intraoral palpation of s tomatognathic mus cles • The masticatory, infra- and suprahyoidal muscles can be palpated for tenderness and trigger points in cases where myofascial symptoms are present (Travell & Simons 1983). • The masseter can be palpated intraorally (using a gloved little nger, index nger or thumb) at its origin along the zygomatic arch and extraorally from inferior to the zygomatic arch moving inferiorly and posteriorly to the angle of the jaw. H ave the patient clench their teeth to locate this strap-like muscle extraorally. • The temporal branch can be palpated intraorally (using a gloved little nger) as it inserts into the coronoid process of the mandible and extraorally by asking the patient to clench their teeth and palpating the fan-like muscle at its temporal location.
Extra o ra l p a lp a tio n
Table 3.2 Neural tissue palpation sites
Nerve
Site
Supraorbital branch o the ophthalmic nerve
In the eye brow
Temporalis o the craniolateral acial nerve o musculus orbicularis oculi
Laterally o the eye brow
Nasociliary branch o the ophthalmic nerve
Laterally at the nose
In raorbital nerve o o the maxillary nerve
Below the middle o the eye on the maxilla
Zygomatic branch o the acial nerve
Over the zygomatic arch
Posterior auricular nerve o the acial nerve
Over the petrous portion o the temporal bone, 5–18 mm behind the external auditory meatus
Auriculotemporal branch o the mandibular nerve
Between the external auditory meatus and the mandibular head, usually during mouth opening
Buccal branch o the mandibular nerve
Below the zygomatic bone, over the buccinator
Mandibular branch o the acial nerve
Ventrally o the parotid gland on the super cial masseter, usually during light contraction
Lingual branch o the mandibular nerve
Anteriorly and internally o the mandibular angle, just anterior o the medial pterygoid muscle
Mental nerve o the mandibular nerve
Laterally on the chin
• The lateral pterygoid can be palpated extraorally, by rmly pressing medially, just anteriorly of the mandibular head and possibly intraorally by entering the maxillary buccal vestibule then moving superiorly, posteriorly and medially towards the insertion on the condyle of the mandible. • The practical application of intraoral palpation of the lateral pterygoid and its validity and reliability are disputed.
• Medial pterygoid can be palpated extraorally at the medial side of the angle of the mandible. • O f the suprahyoidal muscles, the digastric muscle might show trigger points in its anterior belly, extraorally palpated at the caudad surface of the oor of the mouth, as well as in the posterior belly behind the ramus of the mandible. Intraoral palpation of the oor of the mouth may reveal a tender or trigger point of the mylohyoid muscle. • The infrahyoidal omohyoideus muscle with a sling dividing the superior and inferior bellies may be damaged by anterior neck surgery, possibly leading to insuf ciencies in swallowing and speech. O ccasionally the lower belly shows local tenderness and tightness, which might interfere with the superior brachial plexus so causing neurogenic arm pain. • Any reproduction of pain on muscular palpation indicates an immediate symptomatic treatment option with passive techniques (massage, trigger point, electromassage, elastic taping) or active rehabilitation aimed at muscular relaxation and rebalancing. • Further examination is required to establish the cause of the myogenic nding.
Intraoral obs ervation and palpation • Resting position o the mandible: part the patient’s lips to reveal the incisors. ○ the teeth should be slightly separated and the incisors should be aligned. If the mandible is deviated, correct this and assess the effects this has on the patient’s symptoms. • M alocclusion: look for open bite, cross bites, retro- or prognathic malposition, missing teeth (Fig. 3.33). ○ ask the patient to bite, noting any pain, then part the lips and note whether there are any signs of malocclusion such as contact of the teeth on one side more than the other or overbite due to lack of posterior support. This will force the mandible into retraction, compressing the pain-sensitive retrodiscal tissue. • Inspection o the teeth: ask the patient to open the mouth and look for excessive wear 115
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6 7 4 2
3 5
1 2 3 4 5 6 7
Fig ure 3.33 • Open bite in central relation. (Reproduced with the permission of the IFCFS.).
patterns on the teeth, which may be related to bruxism ○ palpate and press the teeth in buccal, lingual, oral, palatinal directions to assess pain ○ look for periodontologic signs such as gingival recession, clefts or swellings (garland), which could by a sign of periodontal disease or parafunctional activity such as bruxism ○ the latter might cause swelling at the oral side of the cheek as well, when patients suck the cheek between the teeth. • The resting position o the tongue should be relaxed at the oor of the mouth. At swallowing (closed lips) the tip of the tongue should rest against the anterior part of the upper palate just posterior to the upper incisors. Ask the patient to swallow and then ask where the tongue was pressing during swallowing. • Inspection o the tongue: due to parafunctional habits, abnormal swallowing patterns or speech abnormalities, the tongue may push against the upper (or lower) teeth or between them and indentations of the teeth on the tongue will be the result.
Ac c e s s o ry mo ve me nts The basic examination consists of seven accessory movements, which may need to be assessed in neutral or functional positions of the TMJ and the cervical spine (Fig. 3.34). These tests are considered speci cally for peri- and intra-articular structures and allow further structural interpretation of the dysfunction (Langendoen et al. 1997, 116
Longitudinal caudad Posteroanterior Anteroposterior Transverse medially Transverse laterally Longitudinal cephalad Posterocephalad
1
Fig ure 3.34 • Graphic representation of standard accessory movements of the mandible in a TMJ with an anterior displaced disc. (Reproduced with the permission of the IFCFS.)
Bumann & Lotzmann 2000). All movements can be performed intraorally, whereas adequate extraoral end-of-range assessment is limited to the transverse movements. The seven movements are, in the order of intraoral application: • • • • • • •
longitudinal caudally posteroanterior anteroposterior transverse medially transverse laterally longitudinal cranially longitudinal dorso-ceph.
Most accessory movements can be used as treatment techniques. Indication, contraindication and type of performance have to be considered carefully according the clinical condition, the structural diagnosis and the overall management aims and plans.
Extraorally applied acces s ory movements Tra ns ve rs e move me nt me d ia lly (Fig. 3.35) • Direction: Movement of the condyle of the mandible in a transverse medial direction in relation to the mandibular fossa.
Ac c e s s o ry m o ve m e n ts
Fig ure 3.35 • Extraoral application of a transverse medial accessory movement with xation of head and neck and palpation of the contralateral joint.
Fig ure 3.36 • Transverse position of the tip of the right thumb at the last contralateral, left, molar, while palpating the left TMJ and xating the head with the ipsilateral hand and anterior shoulder.
• Symbol: • Patient starting position: Side lying with the head supported on a pillow. O ccasionally in supine lying with the head on a pillow and turned to the left, if that is considered relevant. • Therapist starting position: Standing behind the patient’s head facing across the patient’s body.
• Care must be taken to make sure the movement is as comfortable as possible.
Localization o orces (position o therapist’s hands) • The pads of both thumbs are placed over the head of the mandible pointing towards each other. • The backs of the thumbs may be positioned close together. • The ngers of both hands spread comfortably around the thumbs to provide stability. • The arms must be directed in line with the transverse movement of the mandible. • Alternatively, to reduce pressure discomfort, apply the movement with the ipsilateral thenar, while the other hand xes the head and neck and palpates the contralateral joint with the index nger.
Application o orces by therapist (method) • Small amplitude (grade I) oscillatory mobilizations are produced by the therapist’s arms acting through stable thumbs. • Very little pressure is required to produce quite a lot of movement.
Interpretation o f ndings • Ipsilateral pain and movement limitation indicates an intra-articular obstruction such as a displaced disc or brosis after trauma. • Contralateral pain indicates a capsular dysfunction, either an acute capsulitis or a painful stiff capsular tightness.
Uses • The main indication is an end-range intraarticular condition, for example, due to brosis after trauma or surgery. • The effect on the contralateral joint is a transverse lateral movement, which might be an indicated treatment direction in painful or stiff periarticular conditions. Avoidance of ipsilateral local pressure pain is a major advantage of contralateral application.
Intraorally applied acces s ory movements (Figs 3.36 and 3.37) Longitud ina l move me nt c a ud a d • Direction: Movement of the head of the mandible in a longitudinal direction caudad in relation to the mandibular fossa. • Symbol: 117
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Fig ure 3.37 • Intraoral application of accessory movements in a functional position of the mandible with xation of head and neck.
Fig ure 3.38 • A bilateral longitudinal caudad movement can be applied as a treatment technique in various rhythms, grades and positions of the mandible.
• Patient starting position: Supine, lying over towards the therapist. • Therapist starting position: Standing by the patient’s side, level with the shoulder.
Uses
Localization o orces (position o therapist’s hands) • The left thumb is placed intraorally and transversely at the occlusal surface of the most posterior molar. The left index and middle nger are around the angle of the mandible. • The right hand and arm stabilize the patient’s head with one nger of the right hand in a position to be able to palpate for movement of the right TMJ.
Application o orces by therapist (method) • While the therapist’s right hand stabilizes the patient’s head, the therapist exerts pressure against the right lower molar so as to distract the TMJ. • This is best produced as an oscillatory movement at the limit of the range.
Interpretation o f ndings • Decrease of pain indicates an intra-articular source of pain, as well as an option for treatment. • Early pain reproduction without resistance indicates an acute capsulitis; with stiffness it indicates a more longstanding capsular limitation. 118
• Mobilization in a caudad direction is the most commonly used articular treatment technique. • The caudad movement is most useful as a technique to stretch into when there is limitation of mouth opening due to tightness of the joint’s capsular structures. • G rade II mobilizations without pain may be bene cial to support management of an (sub) acute capsulitis or bilaminar zone in ammation. • Caudad mobilization of a capsular tightness, with or without inclinations, can be bene cial in the case of a coexisting intra-articular disc derangement. • The technique decompresses the joint surfaces enabling improvement of anterior translation of the disc in the upper joint compartment. • Note: posterior-anterior movement of the mandible stimulates translation in the lower compartment, possibly increasing the intraarticular dysfunction and might not positively in uence the discal translation. • A more forceful variation of the technique for mobilizing a stiff capsule is performed by supporting the treatment hand at the wrist with the other hand into caudad direction, while controlling the patient’s head position with the anterior side of the shoulder. • A lighter, more subtle variation of the technique, mainly for relaxation, is a bilateral application with the index and middle nger in various positions of the mandible (Fig. 3.38).
Ac c e s s o ry m o ve m e n ts
P os te roa nte rior a nd a nte rop os te rior move me nt
• Both forearms are directed in line with the posteroanterior movement of the joint.
• Direction: Movement of the head of the mandible in a posteroanterior and anteroposterior direction in relation to the mandibular fossa. • Symbols: , • Patient starting position: Supine, lying over towards the therapist. • Therapist starting position: Standing by the patient’s side, level with the shoulder.
For a nter oposter ior
Localization o orces (position o therapist’s hands) • The left thumb is placed intraorally and transversely at the occlusal surface of the most posterior molar. The left index and middle nger are around the angle of the mandible. • The right hand and arm stabilize the patient’s head with one nger of the right hand in a position to be able to palpate for movement of the right TMJ.
Application o orces by therapist (method) • The movement in these directions is produced by the therapist’s arms acting through thumb, index and middle nger. • The area of contact at the mandibular angle can be uncomfortable with stronger pressure.
Alternative in case intraoral application is not possible • For posteroanterior: standing by the patient’s right shoulder facing across the patient’s body. • For anteroposterior: standing by the patient’s left shoulder facing across the patient’s body.
Localization o orces (position o therapist’s hands) For poster oa nter ior • The pads of both thumbs, pointing towards each other are placed against the posterior surface of the head of the mandible, behind the ear lobe, with the backs of the thumbs close together. • The ngers rest comfortably over the forehead and mandible.
• The pads of both thumbs, pointing towards each other are placed against the anterior surface of the condyle of the mandible as close to the head as is possible without losing contact with the anterior surface of the condyle, with the backs of the thumbs close together. • The ngers spread comfortably around the patient’s forehead, mandible and neck. • Both forearms are directed in line with the anteroposterior movement of the joint.
Application o orces by therapist (method) • The mobilization in these directions is produced by the therapist’s arms acting through both thumbs. • As these areas of contact are normally sensitive to touch it is necessary to position the thumbs carefully and produce the movement with the arms and not the thumb exors.
Variations in the application o orces • The posteroanterior movement can also be produced by making contact with the head of the mandible from within the external auditory meatus. • The anteroposterior movement can be produced by making contact with the ramus of the mandible rather than the condyle.
Interpretation o f ndings • Posteroanterior movement stretches the posterior and compresses the anterior capsule and may be painfully limited in a peri-articular condition. • In the case of an anterior-displaced disc the movement might feel blocked and pain may arise from stretching the already compressed intra-articular ligaments. • Crepitus on movement, often not related to pain, indicates degenerative joint disease. • Anteroposterior movement loads the posterior capsule, compresses the bilaminar zone and will be painful if there is intra-articular in ammation. 119
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• A very limited movement indicates a pathological posterior position of the head of the mandible in the fossa.
Uses • Posteroanteriorly directed movements are only indicated in treatment if increased stiffness is de nitely related to pain(for example, due to brosis after trauma) and the disc-condyle complex is very stable. • Anteroposterior movement is not indicated as a treatment direction in any intra- or periarticular condition as it may interfere with disc-condyle stability and the centric relation by promoting non-physiological translation in the lower compartment.
Tra ns ve rs e move me nt me d ia lly a nd la te ra lly • Direction: Movement of the condyle of the mandible in a transverse medial and lateral direction in relation to the mandibular fossa. , • Symbols: • Patient starting position: Supine, lying over towards the therapist. • Therapist starting position: Standing by the patient’s side, level with the shoulder.
Localization o orces (position o therapist’s hands) • The left thumb is placed intraorally and transverse (medially or laterally) at the occlusal surface of the most posterior molar. The left index and middle nger are around the angle of the mandible. • The right hand and arm stabilize the patient’s head with one nger of the right hand in a position to be able to palpate for movement of the right TMJ. • For the transverse lateral movement, shift the tip of the thumb to the lingual side of the last molar.
Application o orces by therapist (method) • Transverse medially to the mandible by the extraorally positioned index and middle nger and transverse laterally by the thumb at the lingual side of the last molar. • The intraoral application enables end-range testing. 12 0
Interpretation o f ndings and uses • Pain and movement limitation on transverse medial movement indicates an intra-articular obstruction such as a displaced disc or brosis after trauma. In stiffmess without disc derangement this technique (grade III/ IV) can be applied for treatment. • Pain and movement limitation on transverse lateral movement indicates a capsular dysfunction, either an acute capsulitis or a painful stiff capsular tightness. These conditions can be managed with a painless resistance-free (grade II) application and a end-range technique with some pain (grade III−/ IV−, or III/ IV) respectively.
Longitud ina l move me nt c e p ha la d a nd p os te roc e p ha la d • Direction: Movement of the head of the mandible in a longitudinal direction both cephalad and posterocephalad in relation to the mandibular fossa. • Symbol: • Patient starting position: Supine, lying over towards the therapist. • Therapist starting position: Standing by the patient’s side, level with the shoulder.
Localization o orces (position o therapist’s hands) • The left thumb is placed intraorally and transversely at the occlusal surface of the most posterior molar. The left index and middle nger are around the angle of the mandible. • The right hand and arm stabilize the patient’s head with one nger of the right hand in a position to be able to palpate for movement of the right TMJ.
Application o orces by therapist (method) • The technique is one of pushing cephalad respectively posterocephalad in different functional starting positions of the mandible (medially, neutrally, laterally, anteriorly positioned) to load the mandibular fossa at various points.
Interpretation o f ndings • With the disc in place, the cephalad movement can never be painful.
Ac c e s s o ry m o ve m e n ts
• Any pain indicates an intra-articular disorder. Posterocephalad pressure speci cally loads parts of the bilaminar zone and the discotemporal ligament, which can be painfully in amed, even in absence of a disc displacement.
Uses • The cephalad and posterocephalad movements are never treatment directions.
Conclus ion After examination of the TMJ with accessory movements and a subsequent reassessment of the relevant ndings, a clinical conclusion about the intra- and periarticular status should be made. An initial treatment for an intra- or periarticular condition may follow and examination of further structures, for example: • accessory and passive physiological movements of the upper cervical spine • the cervico-thoracic junction and upper ribs • functional muscle tests of relevant neckshoulder girdle muscles, are to be performed during the next sessions. The conclusions might need to be reported to the practitioners of the other disciplines involved and the therapist might contribute to the formulation of the overall management plan. It might be appropriate to assess the function of an existing splint, to perform instrumental measurements, for example, • • • •
jaw motion analyzer electromyography of the masticatory muscles heart rate variability recording and/ or imaging procedures such as functional magnetic resonance imaging in the case of an arthropathy
Fig ure 3.39 • Examination and treatment of the hyoid bone.
• Screening with simultaneous palpation of hyoid and laryngeal structures with coughing, swallowing and talking.
Tra ns ve rs e a nd rota ry move me nt of the la rynge a l a nd hyoid joints • Direction: Transverse or rotary movement of the cricothyroid joint in relation to the hyoid bone or the hyoid bone in relation to the mandible and cricothyroid cartilage. • Symbols: , • Patient starting position: Supine, lying without a pillow so that neither the head nor neck is exed. An extended examination might require repetition of the routine tests in different positions of the upper cervical spine and mandible. • Therapist starting position: Standing by the patient’s side, facing across the patient.
Localization o orces (position o therapist’s hands)
Othe r s truc ture s in p la n
Movement of the thyr oid ca r tila ge
Further examination may complete the rst session or may follow in the next session.
• The thumb and index nger of the left hand loosely grasp the upper margin of the thyroid cartilage. • The thumb and index nger of the right hand loosely grasp the lower margin of thyroid cartilage. • The ngers spread forwards over the adjacent neck, chest and face. • The little ngers make the rmest contact.
Hyoid and larynx (Fig. 3.39) • Resting position of the hyoid bone, which can be located anteriorly just below the mandible at the level of C3.
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Movement of the hyoid bone • The index nger and thumb of the left hand hold the hyoid bone. • The right hand stabilizes the thyroid cartilage or the head.
Application o orces by therapist (method) • Movement of the thyroid cartilage away from the therapist is produced by pressure through the thumbs. • The little ngers form a pivot about which the thumb movement takes place. • To make the pressure as comfortable as possible the movement should be produced by glenohumeral joint adduction and slight elbow extension rather than by the thumb exors. • Movement of the thyroid cartilage towards the therapist is produced by the opposite movement of the therapist’s arms acting through the index ngers. • A rotary movement can also be performed. • The hyoid bone can be moved from side to side as well as rotated around a sagittal axis, with the index nger and the thumb in different positions of the upper cervical spine and mandible to assess its mobility and any pain response to movement. • Particularly note small asymmetries in mobility accompanied by subtle discomfort.
Uses • When transverse or rotary movements of the laryngeal and hyoid joints are painful, gentle and slow painless movements are performed. • Sustained gentle hyoid techniques are used for local or deep relaxation within a standardized protocol. • H yoid reassessment may con rm the effectiveness of soft tissue management for tight supra- and infrahyoidal muscles.
Occlus al–cervical–pelvic relations hips The theory of and evidence for the Emotional Motor System may provide an explanation for the 12 2
Meersseman Test (Esposito & Meersseman 1988, H olstege et al. 1996, van der H orst et al. 1997, 2001, G errits et al. 1999, 2004, H olstege 2001, H uelse & Losert-Bruggner 2002, Mouton et al. 2005, Entrup 2009, Fischer et al. 2009). An algorithm for clinical application of the Meersseman test procedure could be: 1. Measure in standing with closed lips and discluded teeth: a. the nger to oor distance and/ or b. lumbar unfolding at lumbar exion (relate to pelvic tilt) and/ or c . heel to heel distance at bilateral hip abduction and/ or 2 below. 2. Measure in supine lying the range of motion of: a. straight leg raise and/ or b. hip abduction and/ or c . hip extension for iliopsoas length (Thomas test). 3. Then reassess the most relevant test(s) (1a–c, 2a–c): a. during full intercuspation b. at biting with cotton rolls between the molars, uni- or bilaterally (as in Fig. 3.20), depending occlusal assessment c . after upper cervical mobilization d. after taping to relax chewing muscles (see Fig. 3.52). Another, reversed, algorhythm could be: 1. Assess maximum mouth opening in supine lying. 2. Reassess after: a. active lengthening of tensed muscles (hamstrings and or adductors) and/ or b. taping for relaxation of the hamstrings or adductors or psoas or c . upper cervical mobilization. Integration of the test procedure in Rx1 or Rx2 is indicated in extra-articular conditions such as occlusal faults or parafunctional habit-induced hyperactivity of the chewing muscles with or without complaints in the lower low back–pelvic hip area.
Cranium • Skull bones are able to move in young years and may still be able to adapt to stress and loading – able to ‘breathe’ – after adolescence.
Ac c e s s o ry m o ve m e n ts
• Sutures contain nerve receptors and can be considered a possible source of symptoms. • Skull development and alteration of transmission of forces between the skull bones may well result in painful conditions (headaches) and a whole array of bizarre symptoms such as loss of concentration, dizziness, altered behaviour, weeping, bed-wetting, loss of senses, etc., not only in the young. • Apart from inter-cranial forces, cranial bones are an interesting and challenging medium between the forces of the extracranial muscles and the intracranial meninges. • This implies that related muscles and neuromeningeal structures, if not treated, still have to be assessed and reassessed when dealing with skull techniques. • Techniques which assess the response of the brous suture lines of the skull to pressure changes have been described in traditional craniosacral therapy (Liem 2000). • Cranium techniques have been integrated into the Maitland Concept of assessment and management of neuromusculoskeletal dysfunctions (von Piekartz & Bryden 2000). A number of commonly used techniques aiming to decrease TMD/ O FP symptoms of extra-articular origin such as muscular pain, headaches due to parafunctional habits (e.g. bruxism), as well as other symptoms, which might indicate (benign) dysfunctions of cranial nerves possibly due to cranium dysfunctions (suturae, foramina) are described, however, a full description of all techniques is beyond the scope of this book. H ypothethical rationales for the techniques are: • Rebalancing of the autonomous nervous system, deep relaxation to stimulate the parasympathetic part, particularly the nucleus ambiguus (measurable with heart rate variability) (Marthol et al. 2006). • Rebalancing the extracranial structures (muscles, muscle attachments) with the intracranial meninges and their cranial attachments. G enerally, there are three ways, attitudes or visions for using cranium and craniosacral techniques (Ridley 2006), which can be related the Maitland grading system (Banks & H engeveld 2005):
1. H igh intervention (corresponding with grade IV− to IV+). Either direct techniques, using forces to move the bones or indirect when a perceived motion is followed to the end and kept. Both methods are structure–function models. A change in structure will change function (direct, immediate, transient?), whereas function changes lead to structure rebalancing (indirect, slower, more permanent?). 2. Light intervention (corresponding with grade II): A perceived motion is followed, however, not kept till relaxation or normalization occurs. 3. ‘No’ intervention: manual contact is just following breathing movements till changes in rhythm or movements and relaxation occurs (grade I). • Patient starting position: for the described techniques the patient should comfortably lying supine on a treatment plinth with or without a pillow. • Therapist starting position: apart from for the maxilla and mandibula techniques, sitting behind the head of the patient.
Oc c ip ut-C1 longitud ina l c e p ha la d (Fig. 3.40) • This technique is a typical example of a direct, high-intervention technique, aiming to restore function at the junction, which includes relaxation of the suboccipital muscles and even the dura mater.
Localization o orces (position o therapist’s hands) • Both hands are left and right posteriorly at the caudad occiput. • The forearms are relaxed on the plinth. • Fingers II to V move in as gently and slowly as possible towards O cc-C1.
Application o orces by therapist (method) • Apply a sustained IV−−, IV− longitudinal cephalad at the occiput for one or two minutes. • Follow this with a longitudinal caudad movement applied by the index and middle nger, while the ring nger and little nger keep the longitudinal cephalad pressure on. 12 3
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Fig ure 3.40 • Longitudinal cephalad technique for relaxation of occiput-C1.
Fig ure 3.41 • Temporal bone. Bilateral medial technique.
Bila te ra l c irc umfe re ntia l (Fig. 3.42) Localization o orces (position o therapist’s hands) • The index nger tip at the zygomatic bone, the middle nger tip in the external auditory meatus, the ring nger tip at the mastoid process.
Application o orces by therapist (method)
Temporal bone
• Apply a combined movement, exion–extension and internal rotation – external rotation around an oblique axis around the petrous portion of the temporal bone. • The traditional order of the technique is: 1. bilaterally symmetrically 2. feel for easier side, move that side as described rst 3. the same with the more dif cult side 4. both sides opposed.
Bila te ra l me d ia l – la te ra l (Fig. 3.41)
Bila te ra l c a ud ola te ra l (Fig. 3.43)
Localization o orces (position o therapist’s hands)
Localization o orces (position o therapist’s hands)
• Both hands are left and right posteriorly at the occipital condyles and mastoid process. • The forearms are relaxed on the plinth.
• Thumbs are positioned at the lower border of the external auditory meatus.
Fig ure 3.42 • Temporal bone. Bilateral circumferential technique.
• Finally, gentle rocking in exion–extension direction induced by the wrists of the therapist adds a mobilizing component.
Application o orces by therapist (method) • Both thenars apply a sustained alternating medial (lateral) pressure (IV−−) 12 4
Application o orces by therapist (method) • Thumb pulls bilaterally simultaneously in a laterocaudad direction (towards the acromion) (temporal decompression).
Ac c e s s o ry m o ve m e n ts
Fig ure 3.43 • Sustained caudolateral movement by pulling at the lower border of the external auditory meatus in the direction of the acromioclavicular (A/C) joint (decompression of temporal bone).
Fig ure 3.44 • Sustained longitudinal cephalad movement (TMJ compression) with middle and ring nger under the body of the mandible for local and deep relaxation.
Application o orces by therapist (method) • Apply a sustained IV−− longitudinal cranially at and just anteriorly of the angle of the mandible.
Traditional rationale • Movement of the temporal bone over the parietal bone and tensioning of the cerebral falx.
Fig ure 3.45 • Sustained longitudinal caudad movement (TMJ decompression) with index, middle and ring nger at the mandible for local and deep relaxation.
TMJ : bilateral longitudinal (compres s ion – decompres s ion) Bila te ra l longitud ina l c e p ha la d (p ha s e 1,c omp re s s ion) (Fig. 3.44) Localization o orces (position o therapist’s hands) • Tips of the middle and ring ngers are at the caudad side of the body of the mandibula and the mandibular angle, while the rest of the hand is lying relaxed on the face and the thumb on the frontal bone.
Bila te ra l longitud ina l c a ud a d (p ha s e 2, d e c omp re s s ion) (Fig. 3.45) Localization o orces (position o therapist’s hands) • Tips of the index, middle and ring ngers are on the body of the mandibula and the mandibular ramus, while the little nger is relaxed without face contact and the thumb is lying relaxed on the frontal bone.
Application o orces by therapist (method) • Apply a sustained longitudinal caudal movement (IV−−) rst, then gradually change to a 30° anterior angle during the expiration phase of the breathing cycle. • Feel for relaxation.
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Mandibula
Localization o orces (position o therapist’s hands)
Bila te ra l longitud ina l c a ud a d (d is tra c tion) • The tips of the index and middle ngers of one (Fig. 3.38) hand are intraorally on the occlusal surface of • Therapist starting position: Standing next to one shoulder of the patient.
Localization o orces (position o therapist’s hands) • The tips of the index and middle ngers of one hand are intraorally lying on the most posterior left and right mandibular molars.
Application o orces by therapist (method) • Apply a sustained longitudinal caudal movement (IV−−) rst, then gradually change to a 30° anterior angle during the expiration phase of the breathing cycle. • Feel for relaxation.
Rationale • Release of the temporal fascia.
the posterior maxillary molars left and right, while keeping the other hand at the head (sphenoid bone).
Application o orces by therapist (method) • First, feel for medial–lateral movement of the hard palate (maxilla), then rstly apply a sustained bilateral lateral movement (IV−−) and, after having monitored some relaxation, follow this with an anterocephalad movement (IV−−).
Sphenoid bone (Fig. 3.47) Ante rop os te rior (c omp re s s ion) a nd p os te roa nte rior (d e c omp re s s ion) Localization o orces (position o therapist’s hands)
Maxilla (Fig. 3.46)
• Both forearms are relaxed lying on the plinth, both hands are controlling the mastoid process and occipital bone. The tips of the thumbs are positioned at the sphenoid bone just cephalad of the zygomatic arch on both sides.
La te ra l, a nte roc e p ha la d
Application o orces by therapist (method)
• Therapist starting position: Standing next to one shoulder of the patient.
• Anteroposterior (compression): Apply with the thumbs a bilateral sustained posterior
Fig ure 3.46 • Sustained bilateral lateral or anterocranial movement of the maxilla, applied at the upper molars.
Fig ure 3.47 • Bilateral anteroposterior (compression) and posteroanterior (decompression) movement of the sphenoid bone with both thumbs while xating the head and the neck with both hands.
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movement (IV−−), while both hands stabilize the occiput. • Posteroanterior (decompression): the same anteriorly.
Management • Due to the complexity of the craniomandibular region, disorders, which manifest as craniomandibular pain or dysfunction, are often multicomponential and multidimensional. • Physical therapy applications are likely to be part of a multidisciplinary, overall short- and long-term management plan of movementrelated disorders of the temporomandibular complex. • O ne provider serves as the leader of the multidisciplinary team, most commonly the dentist. • The patient has to agree with the management plan, which has to pace all relevant context factors. • If long-term management is needed, optimal compliance of the patient is essential. • Initial management aims to decrease the complaints (short-term aim) (Table 3.3) as well as to create an equilibrium before starting de nite management such as teeth restoration (long-term). • Anti-in ammatory drugs, or even a change in hormonal medication, may be indicated. • Adequate dental management with splints (Figs 3.48 and 3.49) and teeth restoration is essential for long-term recovery in the majority of cases with occlusal components. • Physical therapy modalities may be an important support in these cases. • O ther cases might pro t greatly from a large variety of physical, non-dental treatment options with a mechanical or a neurophysiological bias. • As outlined, passive movements of painful or stiff TMJ might be indicated in selected cases within the scope of the overall management. • Accessory movements in functional positions, rather than passive physiological movements, seem to be more appropriate. • Active movements, performed in combination with a sustained accessory movement, for example, active depression with sustained
Fig ure 3.48 • A splint showing physiological incisal guidance.
Fig ure 3.49 • A splint showing physiological canine guidance.
transverse pressure medially, may be bene cial treatment options.
De nitive o c c lus al re s to ratio n/ the rapy afte r s uc c e s s ful/s table s ympto matic the rapy Beyond passive movements, the physical therapist may play a larger role in the overall management, such as: • Active rehabilitation aiming to restore normal quality of mandibular movement • Myofunctional training for lip closing, tongue control and swallowing pattern, postural control, including optimizing cervical mobility and dynamic control 12 7
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Table 3.3 3 × 3 table for primary, symptomatic management of TMD/OFP
Adapted from the Interdisciplinary Forum for Cranio-Facial Syndromes (IFCFS), with permission. Localization
Intra-articular (e.g. bilaminar zone)
Periarticular (e.g. capsulitis)
Extra-articular (e.g. teeth, muscles, cervical spine)
Pain problem
NSAIDs!
NSAIDs!
Teeth pain: dentist
Ice
Ice
Distraction splint?
Centric splint?
Chewing muscles (e.g. masseter trismus –dentist)
Repositioning splint? (only in highly acute cases with intact retrodiscal ligaments) Range-o -motion problem
NSAIDs?
NSAIDs
Ice?
Ice
Distraction splint! 24/7/>6
Centric splint with teeth guidance (build-up in stages)! 24/7?
PT: rotation training MT: contraindicated
PT: rotation training without pain MT: pain- ree longitudinal caudad (+/− angulations) Elastic taping rom the zygomatic bone to the mandibular angle
Chewing and hyoidal muscles: ice, (electro) massage, trigger points (TrP), elastic taping, proprioceptive neuromuscular acilitation (PNF), bio eedback – stress ball (HRV), muscle-relaxing drugs, relaxation splint with incisal and canine guidance Botulinum neurotoxin Oro acial/mimic: myo unctional therapy (lip closing, swallowing) Neurorehab (FOTT (Facial-Oral Tract Therapy – Kay Coombes) Cervical: PAIVMs according degree o dys unction (EOR) (more causally)
End o range
Distraction splint? PT: rotation training Elastic taping rom the zygomatic bone to the mandibular angle? MT: transverse medially
Centric splint with incisal and canine guidance! (24/7/?)
Craniosacral: mechanical/ neurophysiological (more causal therapy)
PT: Rotation training without pain
Neural:
MT: longitudinal caudally (+/− angulations)
‘Sliders’ o impaired neural tissue ollowing treatment o cervical spine, cranium, medication/neurosurgery
EOR = end of range, HRV = heart-rate variability, MT = manual therapy, NSAIDs = non-steroid anti-in ammatory drugs, PAIVMs = Passive accessory intervertebral movements, PT = physiotherapy
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• Extra-articular soft tissue management for myogenic components incl. trigger-point treatment, electrotherapy (relaxing massage) or elastic taping (Figs 3.50, 3.51, 3.52, 3.53 and 3.54). (Sturdivant & Friction 1991, Suvinen et al. 1997, Treacy 1999, Sander et al. 1999, Nicolakis et al. 2000, 2001a, 2001b, 2002, Wolf
et al. 2000, Carlson et al. 2001, O h et al. 2002, Wahlund et al. 2003, Michelotti et al. 2004, McNeely et al. 2006, Medlicott & H arris 2006, G unsch 2007, Fischer et al. 2009, La Touche et al. 2009, Mansilla-Ferragut et al. 2009). Stress coping and management of stress-induced complaints are a common component of the overall
Fig ure 3.51 • Electromassage for bilateral relaxation of the masseter muscles. (Reproduced with the permission of the IFCFS.) Fig ure 3.50 • Treatment of a medial pterygoid trigger point during static mouth opening against slight resistance.
Fig ure 3.52 • Bilateral elastic tape application in myogenic craniomandibular dysfunction to support management for relaxation. The base of the tape is at the zygomatic arch just anterior of the TMJ , the ending is caudad side of the mandible in the midline (tape width is 2.5 cm). The starting position of the mandible is depression short of or at R1. The tape is applied without stretch. (Reproduced with the permission of Kinematic Taping®.)
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Fig ure 3.53 • Bilateral elastic tape application in arthrogenic craniomandibular dysfunction to support rotatory movement training of the condyle. The base of the tape is at the caudad side of the zygomatic bone, the ending is caudad side of the angle of the mandible (tape width is 2.5 cm). The starting position is central relation. The tape is applied without stretch. (Reproduced with the permission of Kinematic Taping®.)
management plan and may include splint, cognitive– behavioural, pharmacological, body-mind and physical therapies. The role of the physiotherapist in this eld may vary from applying local massage or electrotherapy to relax chewing muscles, individual body-mind therapy such as craniosacral therapy, bio- and myofeedback with breathing procedures, to group therapies with a social character such as yoga, qi gong, or meditation classes. Relaxing effects on the autonomic nervous system can be monitored with heart rate variability (H RV) – a way of assessing the state of the parasympathetic nervous system (Shiba et al. 2002, Brown and G erbarg 2005, Cysarz & Buessing 2005, Jovanov 2005, Lee et al. 2005, Khattab et al. 2007, Raghuraj & Telles 2008, Li et al. 2009, Schmidt & Carlson 2009, Asher et al. 2010, Patra & Telles 2010, Tang et al. 2009, H allman et al. 2011, Matsubara et al. 2011, Nugent et al. 2011). 13 0
Fig ure 3.54 • One-sided elastic tape applications in neurogenic craniomandibular dysfunction to support management of mandibular or facial nerve pain. The base of the tapes is at the mastoid process and the zygomatic arch just anterior of the TMJ , the ending is caudad respectively anterior side of the mandible across the midline (tape width is 2.5 cm). The starting position of the mandible is depression, contralateral lateral movement short of P1. The tape is applied without stretch. (Reproduced with the permission of Kinematic Taping®.)
• Long-term active management requires discipline from both the provider and the patient and therefore a routine exercise practice should be promoted intensively. • Rocabado (1985) advocated the use of a daily routine programme in order to maximize patient compliance for craniomandibular rehabilitation. • The 6 × 6 programme includes six instructions, six times each, six times per day. The regime included: 1. learn a new postural position 2. counter the ‘soft tissue memory’ of the old position 3. restore original muscle length 4. restore normal joint mobility 5. restore normal body balance 6. return to the exercise programme when symptoms reappear.
De n itive o c c lu s a l re s to ra tio n / th e ra p y
• A patient-centred (also addressing compliance factors), assessment-related, individual routine self-management may include: 1. memory aids. Use xed times and places, for example, put memory notes (red dots, smileys) for training on the bathroom mirror, near the lavatory, on the steering wheel, on the monitor of the computer, etc 2. favourite numbers: instead of six times per day the patient may prefer other numbers ( ve, seven, ten) 3. train the correct resting position of the mandible: closed lips (mouth closed) and teeth apart, tongue resting at the oor of the mouth 4. train nose breathing with a diaphragmatic breathing pattern. Deep, long breathing cycles initiate relaxation and rebalancing of the autonomic nervous system. Relaxation and/ or dynamic training of the pelvic oor may be necessary 5. train correct swallowing with the anterior one-third of the tongue against the anterior part of the top palate just behind the upper front teeth 6. train correct tongue movements at speaking. Adverse swallowing patterns, inability to keep the mouth closed, adverse tongue movement patterns may demand speci c myofunctional therapy 7. train rotation of the lower TMJ compartment, and avoid anterior translation without rotation of the mandible. With the tip of the tongue placed and maintained at the hard palate and the body ideally aligned, ask the patient to hinge open the mouth. The patient can feel the lateral pole of the condyle for control and should give a low resistance with one thumb to the opening movement. If the tongue stays on the top palate this will reinforce control of ideal rotation of the head of the mandible in relation to the disc and mandibular fossa and reduce the tendency for early translation of the head of the mandible and the disc in the fossa (Fig. 3.55) 8. train cervical posture and control with mandibular function. First, lengthen the cervical spine with the occiput sliding upwards at the door and a minimal chin
tuck, meanwhile maintaining a diaphragmatic breathing pattern. Then, subsequent performance of correct mandible movements, speaking, singing, biting or chewing can be performed. Avoid risky, uncontrolled activities 9. train spinal mobility. This commonly includes, self-mobilization for upper cervical exion and lower cervical, upper (mid, lower) thoracic extension 10. train general posture including shoulder girdle retraction and posterior pelvic tilt. In contemporary practice this relates to the restoration or awareness of functional control of the scapula and spine during arm, head or jaw movements. Be aware of concomitant thoracic outlet or lumbar spine dysfunctions and complaints that need additional management, such as mobilization of the rst rib or rebalancing the relevant pelvic/ hip muscles 11. self-management of chewing-muscle tension with self-massage, trigger-point massage,
Fig ure 3.55 • General exercise for craniomandibular rehabilitation. Opening and closing lips without clenching the teeth and keeping the tip of the tongue at the hard palate to limit opening to the rotatory phase of condylar movement. Subtle resistance with a thumb under the chin aims to relax the masticatory muscles and to restore muscle balance between the masticatory and hyoidal muscles. Variations include manual compression or movement components with the other hand simultaneously applied at the mandible and or functional positions or movements of the cervical spine. 13 1
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electrotherapy, self-taping or wearing the splint during the day time (Figs 3.49–3.54). Development of habit-reversal strategies, for example, a chewing gum parafunctional habit should be reduced to a non-sugar after-meal-only chewing gum routine and in between meals the habit should be replaced by an exercise or relaxation technique. Self-mobilization of the joint capsule is not possible due to the activity of the chewing muscles 12. modern technology enables the patient to use electronic devices, for example, computer software and bio-/ myofeedback machines with electrodes or (anti)stress
balls with coloured light for relaxation and balancing the autonomous nervous system 13. in contrast, traditional activities such as yoga, meditation, qi gong, pilates or oriental dance classes in a pleasant social environment may be just as relevant for regaining a neurophysiological (autonomic) and structural balance 14. conscious living with awareness of distress, adequate stress coping (for example, solving the problem), with discipline and rituals, regular training as well as relaxation, are general, relevant components in overall long-term health management
Cas e s tudy 3.1 The role of mobilization in the management of movement-related temporomandibular joint disorders Mrs H, a 42-year-old community ps ychiatric nurs e has developed a painful click in her jaw when s he opens her mouth. This s he believes has developed in line with occlus ion problems as a res ult of dental work and gum dis eas e. She als o has a very s tres s ful job which does not help.
•
Kind of d is ord e r
His tory (p re s e nt a nd p a s t)
Mrs H indicated that her main problems are: • An inability to fully open her mouth without experiencing a very painful click in her jaw • A s harp pain in the jaw when biting hard • As s ociated pins and needles in her face on occas ions • Tens ion-type headaches when s he is s tres s ed.
•
•
•
•
Are a s of s ymp toms (b od y c ha rt) Mrs H’s areas of s ymptoms are repres ented on the body chart in Figure 3.56.
•
Ac tivity limita tions /24-hour b e ha viour of s ymp toms
•
•
•
•
Mrs H only experienced the painful click on trying to open her mouth fully as in yawning or trying to s hout. She experienced the s harp pain in her jaw when biting hard down on the molars , us ually on the oppos ite s ide to the pain. The pins and needles in the face would only be pres ent for a few minutes as an after-effect of the jaw pain.
13 2
•
The tens ion headaches are only pres ent once or twice per week at the end of the day and the following morning after a s tres s ful day at work. None of her s ymptoms limited her activities , but s he was not able to open her mouth as fully or widely s he could before.
Mrs H had been having a lot of dental work to s tabilize her loos e upper front incis ors which had become loos e due to progres s ive gum dis eas e. She felt s he had altered her bite s o as not to dis lodge her front teeth and, therefore, all her eating now involves us e of the molars . Stres s at work in the las t s ix months was thought to have contributed to the ons et of the tens ion headaches and s he thought the pins and needles had developed with her jaw problem. This was the worrying factor which had led her to s ee her GP, who referred her on to phys iotherapy for exercis es to help her jaw pain. The click had developed s pontaneous ly and had only recently become painful. On further re ection, s he recognized the ons et of the pins and needles at the s ame time as the click became painful. Currently s he is under the care of an orthodontis t.
Me d ic a l s c re e ning q ue s tions •
Routine s pecial ques tions about general health, effects of medication and relevant s creening were unremarkable.
De n itive o c c lu s a l re s to ra tio n / th e ra p y
Cas e s tudy 3.1—cont’d
Patient's Name: Profession: Doctor: Diagnosis Physiotherapist: Date of Assessment: Main Problem:
Patient's Age: Hobbies/Sport:
P's + N's Cough / Sneeze Spinal Cord Cauda eq.
Fig ure 3.56 • Body chart of Mrs H.
13 3
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Cas e s tudy 3.1—cont’d
•
Shoulder, thoracic s pine
,
Pas s ive movements • •
Unilateral PA ( ) C2 s tiff/painful locally Mandible longitudinal caudad (R) and trans vers e lateral (R) s tiff and painful (Fig. 3.58)
R2 (IV+++)
C
a
b
i
l
i
t
Pres ent pain
⁄2
P' I (intensity)
⁄2
1
—
i
r
r
i
t
when opening
IV
1
i
t
y
Headache [2], neck feels s tiff, jaw pain the mouth only.
D
e
•
Screening tes ts
r
• •
Long s lender neck, poking chin with upper cervical s pine in extens ion; correction of this caus ed a s tretching s ens ation in the occiput. Further opening of the mouth did not reveal any functional ins tability of the cervical s pine or any change in s ymptoms . Nas al airways – clear with ins piration right and left. Res ting pos ition of the mandible – deviated to the left, correction of this caus ed . Bite – no overbite but front incis ors maximally intercus pated, balance interference with more contact of the teeth on the left s ide. Ins pection of tongue – indentations of the lower teeth evident around the edge of the tongue.
y—
•
u
Obs ervation
Lateral deviation of mandible to (L) , **Lateral deviation to the right 10 mm s tiff + *Retraction of the mandible 3 mm IV2 overpres s ure Protraction , Hyoid, laryngeal movements , trans vers e and rotary ,
t
P hys ic a l Exa mina tion
• • • • •
a
There was no evidence of red ags or conditions mimicking TMJ dis orders (Kraus 1985).
n
•
S
e
v
e
r
Functional demons tration*** Mouth opening 40 mm click and pain at 30 mm opening, 5° deviation to the left (Fig. 3.57), headache ISQ.
A
⁄4
1
R1 1⁄2 P' I L 3⁄4
B
Caud R TMJ Range
0
Fig ure 3.58 • Movement diagram showing stiff, painful limitation of caudad of the right temporomandibular joint and grade IV mobilization technique.
Deviation to L ‘Click’ 30 mm
Tre a tme nt/ma na ge me nt L 40 mm
•
50 mm
Fig ure 3.57 • Diagram showing mouth opening with deviation and click.
Active movements • • •
Cx Ext 30° s tiff++, headache increas ed, change tongue pos ition ISQ **Cx RR 50° s tiff++, headache ISQ with right lateral deviation of the mandible added ++ Clench teeth , cotton wool ball in left s ide ++, cotton wool ball in right s ide − −
13 4
•
Unilateral PA ( ) mobilization C2 (grade III) – with the effect of improving the pain and s tiffnes s – free range of cervical extens ion and rotation and allowing a further 5 mm of pain-free opening of the mouth. Lateral deviation and retraction of the mandible were unchanged and the click remained the s ame although les s painful. Longitudinal ( ) and trans vers e lateral ( ) movements of the mandible (R) (grade IV) with the mouth open with the des ired effects of res toring the ideal pain-free s tatus of the joint and s tretching the s tructures to regain acces s ory range. This improved the range of opening further and the painful click was les s obvious ; the cervical s pine als o felt freer.
De n itive o c c lu s a l re s to ra tio n / th e ra p y
Cas e s tudy 3.1—cont’d •
•
The des ired effects of the cervical and mandibular mobilization were to act as an adjunct to the home programme (6 × 6) (Rocabado 1985). Mrs H continues to have dental treatment and s till s uffers from the clicking jaw but s he has retained her range of mouth opening and s uffers from fewer tens ion headaches now that her neck is les s s tiff and aching.
•
•
Mrs H is les s worried about her s ymptoms now as s he has a home programme which gives her s ome con dence that s he can control her s ymptoms . The res olution of the s ymptoms , long term, is dependent on the completion of her dental recons truction.
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Phys iotherapy diagnos is and s houlder conditions – the American Phys ical Therapy As s ociation pers pective Other developments and cons iderations in the phys iotherapeutic management of s houlder conditions Integration of the Maitland Concept into contemporary phys iotherapy practice relating to s houlder conditions
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Key words Extended s cope practitioner (ESP), medical diagnos is , phys iotherapy diagnos is , s creening, rotator cuff, impingement, glenoid labrum, glenohumeral joint, ins tability, acromioclavicular joint, imaging, contemporary practice, permeable brick wall
Intro duc tio n If I have seen a little further it is by standing on the shoulders of giants. Sir Isaac Newton (1676)
Sir Isaac Newton’s words could not be more appro priate to describe the contribution made by G eof frey Maitland MBE on the progression of the physiotherapy profession. H e is one of the profes sion’s giants and pioneers and has made an outstand ing contribution to its development and recognition within the medical world. Maitland was passionate about postgraduate education for physiotherapists and signi cantly enhanced our knowledge base and practice in physiotherapy. This has helped to pave
A b rie f in tro d u c tio n to th e ro le o f th e e xte n d e d s c o p e p h ys io th e ra p is t
the way for our current position as autonomous practitioners, and indeed probably helped in the development of physiotherapists into traditional medical roles – roles now termed as extended scope practitioners (ESPs). This chapter aims to demonstrate how many of the fundamental principles on which G eoffrey Maitland developed his concept are still applicable to contemporary physiotherapy practice both for those physiotherapists performing a traditional role and those undertaking an extended scope role. This discussion will be set within the context of disorders affecting the shoulder complex, repeatedly described as one of the most challenging areas in neuro musculoskeletal practice (Robb et al. 2009ab). The complexity of the shoulder and shoulder girdle com bining articulation at the glenohumeral (G / H ), acromioclavicular (A/ C), sternoclavicular (S/ C) and scapulothoracic (S/ Th) joints together with the exceptionally large range of functional demands required and placed upon the shoulder complex provides the background to the challenges facing clinicians. The high prevalence of structural pathol ogy in asymptomatic individuals and common occur rence of multiple co existing structural pathologies further compounds this issue. Although limited to discussion of the shoulder and shoulder girdle, it is hoped that the reader is able to appreciate the applicability of the principles outlined and pre sented in this chapter to the other body regions affected by neuromusculoskeletal conditions. The chapter is structured into ve sections; these are best read as an entirety, consecutively. H owever, they can be read as stand alone sections.
• The two introductory sections (A brief introduction to the role of the extended scope physiotherapist, and Diagnostic considerations – a perspective from the medical profession, an ESP role and the traditional physiotherapy role) discuss the development of extended scope physiotherapy roles and more speci cally address diagnostic considerations as they relate to physiotherapists performing a traditional role and those undertaking an extended scope role. • The third section (Diagnosis and diagnostic titles of shoulder conditions) considers the diagnosis and diagnostic titles of shoulder conditions from a biomedical perspective and discusses the implications for both ESP and traditional physiotherapy practice.
• The fourth section (Shoulder conditions – a perspective from an ESP role) and the fth section (Shoulder conditions – a physiotherapy perspective) discuss the assessment and management of shoulder conditions from the perspective of an ESP and from a traditional physiotherapy role respectively.
A brie f intro duc tio n to the ro le o f the e xte nde d s c o pe phys io the rapis t The United Kingdom’s Chartered Society of Physio therapy (C SP) de nes an ESP as ‘a clinical physio therapy specialist, in any recognized speciality, with an extended scope role, e.g. requesting X rays, scans, blood tests, nerve conduction studies etc.’ Traditionally tasks such as these would have been undertaken by the medical profession, but with additional training and development may be per formed by physiotherapists with an extended role. In the UK, ESPs practice under the Chartered Society of Physiotherapists’ fourth pillar of practice, ‘kindred methods of treatment’ (C SP 2008). This is providing that the member is competent in the activity and able to demonstrate that practice is also linked to the curriculum framework and the World Confederation of Physical Therapists’ (WCPT) de nition of physiotherapy (C SP 2008). Within the UK, physiotherapists who are able to demonstrate these requirements are therefore able to perform tasks in extended roles as part of their individual scope of practice and be covered to practice by the C SP’s Professional Liability Insurance (C SP 2008). Recently, Syme (2009) has developed and published a document on behalf of the ‘Chartered Physiother apists working as extended scope practitioners’, a clinical interest group of the C SP in the UK, enti tled, ‘A resource manual and competencies for extended musculoskeletal physiotherapy roles’ (2009). This document serves as a framework for ESPs to assist individual clinicians in demonstrating their competence to practice speci c tasks in extended roles and hence meet the requirements stipulated by the C SP. ESPs working within the musculoskeletal spe cialty may perform any number of a variety of tasks traditionally undertaken by other professions (C SP 2008). These tasks vary from those with a therapeu tic focus, to those with a diagnostic focus and are 14 3
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dependent upon both the needs of the service in which the individual works and the level to which the individual is educated, trained and competent to undertake the particular task (C SP 2008). As recognized by Syme (2009) ESPs ‘are not homoge nous groups of individuals, even within a speci c speciality’. Some of the tasks typically undertaken by an ESP within the musculoskeletal speciality include:
• Screening referrals to the orthopaedic speciality. • Undertaking orthopaedic assessments and managing G eneral Practitioner (G P) referrals which previously would have been managed by orthopaedic consultants. • Where appropriate and indicated, referring and interpreting investigations including as examples radiological studies, haematology, clinical biochemisty and electrophysiology. • Referring the patient to a variety of other professionals. • Listing the patient directly for orthopaedic surgery. The acceptance of physiotherapists in these roles has largely been due to their ability to demonstrate sound clinical reasoning, forerunners of which were the concepts used by Maitland such as the perme able brick wall (discussed speci cally in the sections on ‘Diagnosis and the Maitland Concept’, and ‘The symbolic permeable brick wall’) and the constant need for continual assessment.
Diag no s tic c o ns ide ratio ns – a pe rs pe c tive fro m the me dic al pro fe s s io n, an ESP ro le and the traditio nal phys io the rapy ro le
• M edical diagnosis is concerned with ‘the determination of the ca use of a patient’s illness or suffering by the combined use of physical examination, patient interview, laboratory tests, review of the patient’s medical records, knowledge of the cause of observed signs and symptoms, and differential elimination of similar possible causes’ (Mosby’s Medical dictionary 2009). • Physiotherapy diagnosis is concerned with classifying the consequences of a patient’s disease, injury or disorder – the impairments, functional limitations and disabilities (WCPT 2007, Zimny 2004, Jette 1989, G ucione 1991). Figure 4.1 serves to highlight this distinction in the concept of diagnosis between the medical and physiotherapy professions, and sets within this, the position of the ESP which is discussed further in the section ‘Diagnosis and the ESP in the neuromusculoskeletal specialty’.
Phys iotherapy diagnos is It is pertinent to revisit the position statement relat ing to the description of physical therapy (physio therapy) published by the World Confederation of Physical Therapy (WCPT 2007) in speci c regard to both the nature of the physiotherapy and consid eration of diagnosis within the profession. Physical therapy provides services to individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan. This includes providing services in circumstances where movement and function are threatened by ageing, injury, disease or environmental factors. Functional movement is central to what it means to be healthy.
Furthermore: Although diagnosis within both the physiotherapy and the medical profession serves a common purpose, namely in determining decisions to be made relating to both the management and progno sis of the individual and also in conveying to the individual information relating to their condition, important differences must be acknowledged. As Jette (1989) has discussed, the primary differ ence in diagnostic classi cation between the medical profession and the physiotherapy profession relates to the phenomena that are classi ed as follows: 14 4
Physical therapy is concerned with identifying and maximising quality of life and movement potential within the spheres of promotion, prevention, treatment or intervention, habilitation and rehabilitation. This encompasses physical, psychological, emotional, and social well being. Physical therapy involves the interaction between physical therapist, patients or clients, other health professionals, families, care givers, and communities in a process where movement potential is assessed and goals are agreed upon, using knowledge and skills unique to physical therapists.
Dia g n o s tic c o n s id e ra tio n s
Physician Medical diagnosis “the determination of the cause of a patient’s illness or suffering by the combined use of physical examination, patient interview, laboratory tests, review of the patient’s medical records, knowledge of the cause of observed signs and symptoms, and differential elimination of similar possible causes” Mosby’s Medical Dictionary, 8th edition (2009) Examples include: 1) WHO ICD 10, e.g. M75.0 adhesive capsulitis of shoulder 2) Other labels, i.e. full/partial thickness rotator cuff tear, SLAP tear, primary subcromial impingement
Physiotherapist with extended MSK role Competency 3 “diagnostic reasoning” - “generate a medical based pathophysiological diagnosis where appropriate or a physiotherapy diagnostic classification based on body structure and function impairments, activity limitations and participation restrictions” (Smye 2009) Competency 4 “selection of diagnostic investigations” where “the extended role physiotherapist selects appropriate ‘medical’ investigations to facilitate the diagnostic process where appropriate” (Smye 2009) Competency 5 “selection of appropriate management strategies” where “appropriate treatment management strategies are arranged at musculoskeletal/ orthopaedic clinics or within the physiotherapy outpatient department” (Smye 2009) Examples as per physician/physiotherapist as appropriate
Physiotherapist Diagnosis “represents the outcome of the process of clinical reasoning and may be expressed in terms of movement dysfunction or may encompass categories of impairments, functional limitations, activity limitations, participatory limitations, environmental influences, abilities/disabilities or syndromes (WCPT 2007) Examples include 1) WHO ICF categories to reflect functional status and activity level 2) Descriptive statement, i.e. functional limitation with putting coat on. Impairment of painful restriction to shoulder internal rotation in abduction 20 degrees. Predominant mechanical nocicpetive pain mechanism, with primary source of periarticular GHJ ie capsule. Contributing factors include apprehension to perform movement due to belief may cause harm and appreciation of possible underlying patho-anatomical lesion, i.e. stage 3 frozen shoulder 3) i.e. humeral anterior glide, scapular downward rotation (Sahrman 2002)
Fig ure 4.1 • Diagnostic considerations and distinctions between the medical and physiotherapy pro ession. WHO = World Health Organization, ICD = International Classif cation o Diseases, ICF = International Classif cation o Functioning.
Diagnosis is considered by the WCPT (2007) as a professional responsibility of physiotherapists and is described as: ‘the result of a process of clinical reasoning which results in the identi cation of existing or potential impairments, functional limitations and abilities or disabilities … The purpose of the diagnosis is to guide physical therapists in determining the prognosis and most appropriate intervention strategies for patients or clients and in sharing information with them …’
This may be expressed in terms of movement dys function or may encompass categories of impair ments, activity limitations, participatory restrictions, environmental in uences or abilities or disabilities. Physiotherapy diagnosis with speci c regard to shoulder conditions is discussed in each consequent
section in this chapter. Physiotherapy speci c issues regarding the assessment, diagnosis and management of shoulder conditions are discussed in the section ‘Shoulder conditions – a physiotherapy perspective’.
Diagnos is and the ESP in the neuromus culos keletal s pecialty As previously discussed in the rst section of this chapter, ESPs in the neuromusculoskeletal speciality may perform any number of a variety of tasks tra ditionally undertaken by other professions (C SP 2008). A common task undertaken by ESPs is to assume the responsibility for establishing an appro priate medical diagnosis on which decisions 14 5
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regarding a patient’s management and prognosis can be determined and communicated appropriately to other health professionals and the patient. With regard to this requirement, three competencies described by Syme (2009) are particularly relevant and are detailed in Figure 4.1. In contrast to the physiotherapy diagnosis, which seeks to guide deci sions regarding the physiotherapeutic management of a patient, the medical diagnosis provided by the physician or the ESP seeks to determine the type of treatment required in the management of the patient. With respect to shoulder conditions, treat ment options that are commonly employed include medications including analgesics, NSAIDs and oral steroids (G reen et al. 1998, Buchbinder et al. 2006), corticosteroid injections (Buchbinder et al. 2003), physiotherapy (G reen et al. 2003), arthrographic distension (Buchbinder et al. 2008), ultrasound guided barbotage, acupuncture (G reen et al. 2005), topical glyceryl trinitrate (Cumpston et al. 2009) and a variety of surgical procedures (Singh et al. 2010, Coghlan et al. 2008, Pulavarti et al. 2009, Tamaoki et al. 2010).
The diag no s is and diag no s tic title s o f s ho ulde r c o nditio ns Diagnos is and the Maitland Concept A fundamental principle central to the evolution of the Maitland Concept was Maitland’s explicit under standing of the dif culties, limitations and obstruc tions to patient management should treatment be directed by the medical diagnosis alone (Maitland 1986). Maitland recognized that ‘even within medi cine, many diagnostic titles are sometimes inade quate, incorrect, or they may be merely linked with patterns of symptomatology, they may even be sup positions’. Acknowledgement of the incompleteness and controversies in the theoretical understanding of pathology further added to this contention. Fur thermore, using evidence from Macnab (1971), Maitland demonstrated how a single clinical presen tation may have several diagnostic titles and con versely how a single diagnostic title may present with several clinical presentations further supporting this opinion (Maitland 1986 p 6). Maitland advocated that the manipulative physio therapist should adopt a mode of thinking (two 14 6
compartment) unique to the Maitland Concept. This has become the symbolic permeable brick wall which lies at the heart of the concept, whereby thoughts regarding the theoretical aspects of a patient’s presentation (known and speculative) are separated from the clinical evidence in the clini cian’s mind. Maitland felt that such a mode of think ing ‘prevents thoughts relating to the theory of a disorder overriding the clinician’s decision making processes and does not inhibit the clinician from discovering the patient’s disorder in terms of its history, its symptoms and its signs in ne detail. It allows for safe and effective management of disor ders where there is an incomplete or uncertain diag nosis’. This concept allows the clinician to base intervention primarily on clinical evidence, i.e. ‘the primacy of clinical evidence’, while acknowledging and drawing on evidence from the theoretical com partment for the purpose of hypothesis generation and testing and the choice of treatment technique. Maitland (1986) stated that ‘by basing treatment on symptoms and signs useful treatment may be effected while the medical profession and its scien tists continue to work towards understanding more in regard to diagnostic titles’. Forty six and forty years on, respectively, since publication of the rst editions of M aitland’s Vertebral M anipulation and M aitland’s Peripheral M anipulation, and the initial development of the Maitland Concept, a wealth of research relating to problems and conditions affecting the shoulder complex has been published in specialties such as anatomy, biomechanics, pathology and diagnosis. A review and appraisal of the fundamental principles on which the Maitland Concept lies in light of con temporary scienti c ndings is therefore necessary to examine its role and applicability in the current evidence based climate of health care provision. The issues surrounding the diagnosis and use of diagnos tic titles in shoulder conditions is one such funda mental principle of the Maitland Concept which requires critical evaluation.
The biomedical pers pective Dia gnos tic la b e ls a nd s hould e r c ond itions Beyond the broader concept of ‘shoulder pain’ numerous diagnostic labels have been applied to conditions affecting the shoulder. The derivations of these labels are varied such as ‘painful arc
Th e d ia g n o s is a n d d ia g n o s tic title s o f s h o u ld e r c o n d itio n s
syndrome’, directly labelled from the clinical signs and symptoms, whilst others such as ‘rotator cuff tendonitis’ are derived from hypotheses regarding the pathology producing the clinical signs and symp toms. The pathoanatomical model on which the majority of diagnostic titles are derived seeks to explain the source of the patients presenting symp toms and signs based on the presence of speci c structural pathology identi ed through isolated or combined physical examination, imaging and histo pathological analysis. It has been proposed by some authors that identi cation of a speci c structural pathological diagnosis on which clinical decisions regarding patient management can be made is essen tial to improving treatment outcomes (G reen et al. 1998, Cyriax 1982). In contrast, as discussed, Maitland (1986) viewed the diagnostic or theoreti cal considerations related to a patient’s presentation secondary in importance to the ‘clinical evidence’ (presenting signs and symptoms) on which the clini cian’s decision making processes are based. The nomenclature used to describe and de ne shoulder conditions in the international literature is extremely varied, as illustrated in Box 4.1. In
1998, G reen et al. demonstrated and con rmed the lack of uniformity in the way shoulder condi tions were labelled and de ned for the painful shoulder. In a systematic review of 24 randomized controlled trials of interventions which speci ed a distinct diagnosis to characterize the study sample, only 16 provided de nitions of the subgrouping strategy. Furthermore, the selection criteria used to de ne the shoulder disorders studied demon strated no between study standardization and indeed in many cases con icting criteria were often used to describe the same type of condition in different studies. Ten years on since G reen et al.’s (1998) observation and analysis, Schellingerhout et al. (2008) reported that the criteria used to de ne diagnostic labels for shoulder pain in rand omized controlled trials (RCTs) which investigate treatment for shoulder pain with a speci c diagnosis continue to fail to demonstrate uniformity. This variability in the criteria used to classify a diagnosis in research is illustrated in Table 4.1. In recognition of this lack of uniformity of nomen clature, several attempts at standardizing the use of diagnostic labels using classi cation systems have
Box 4 1 Examples o terminology or diagnostic titles associated with shoulder problems Re ad c o de s (us ed by GP practices to allow diagnos is to be recorded); the mos t commonly us ed include: s houlder s yndrome, s prained s houlder, rotator cuff s houlder s yndrome, s houlder joint pain, s prain s houlder/ upper arm, arthralgia-s houlder (Lins ell et al 2006) Inte rnatio nal c las s i c atio n o f dis e as e s (ICD-10, WHO 2010) M75 0 adhes ive caps ulitis of the s houlder (frozen s houlder, periarthritis of the s houlder), M75 1 rotator cuff s yndrome (rotator cuff or s upras pinatus tear or rupture (complete or incomplete) not s peci ed as traumatic, s upras pinatus s yndrome), M75 2 bicipital tendinitis , M75 3 calci c tendinitis of s houlder, calci ed burs a of the s houlder, M75 4 impingement s yndrome of the s houlder, M75 5 burs itis of s houlder, M75 8 other s houlder les ions
Othe r te rms Shoulder pain, non-s peci c s houlder pain, mechanical s houlder pain, caps ular s yndrome, acute burs itis , burs al reaction, acromioclavicular s yndrome, s ubacromial s yndrome, rotator cuff tendinitis /tendinos is / tendinopathy, s upras pinatus tendinitis /tendinos is / tendinopathy, s houlder tendinitis , bicipital tendinopathy, rotator cuff tear, impingement s yndrome, s ubacromial impingement, primary impingement, s econdary
impingement, rotator cuff dis eas e, pain arc s yndrome, calcifying tendinitis , calci c tendinitis , tendinitis calcarea, internal impingement, anterior internal impingement, pos terior internal impingement, partial thicknes s /full thicknes s /mas s ive rotator cuff tears als o des cribed by pos ition or type, s capular dys kines is , s capular dys function, numerous clas s i cation s ys tems as s ociated with les ion of the glenoid labrum, numerous clas s i cation s ys tems as s ociated with ins tability of the s houlder Examples : de Winter et al (1999), Lewis (2009), Kibler and Scias cia (2010), Awerbuch (2008), Feeley et al (2009), Beaudreuil et al (2009), Kuhn (2010), Smith and Funk (2010)
Exa mp le s of d ia gnos tic la b e ls us e d within p hys iothe ra p y lite ra ture Impaired joint mobility, motor function, mus cle performance and range of motion as s ociated with: caps ular res triction, ligament or connective tis s ue dis orders (s houlder ins tability), localized in ammation (Tovin & Green eld 2001) Scapular downward rotation s yndrome, humeral anterior glide s yndrome (Sahrmann 2002) Derangement, dys function- articular, dys function – contractile, pos tural (McKenzie & May 2000)
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Table 4.1 Criteria used to def ne a variety o shoulder diagnoses or research purposes
Diagnostic label/concept
Criteria used to def ne diagnostic label – examples
Shoulder impingement syndrome
More than 30 di erent inclusion and 40 di erent exclusion criteria identif ed across the 16 RCTs reviewed by Kromer et al. (2009) Only 4 o 15 RCTs (two o which were the same study at a di erent ollow-up periods) which were reviewed by Schellingerhout et al. (2008) used the same combination o inclusion criteria
Adhesive capsulitis/ rozen shoulder/pain ul sti shoulder
Absence o consistent description o clinical presentation across 21 RCTs reviewed by Schellingerhout et al. (2008). Inconsistency with degree, type (active or passive) and direction o restriction o shoulder movement (Schellingerhout et al. 2008)
Calcif c tendonitis
9/13 RCTs reviewed by Schellingerhout et al. (2008) used the Gartner radiological classif cation system, with a range o additional inclusion criteria between studies
Rotator cu tendinopathy/ including terms such as rotator cu tendonitis/ tendinosis/supraspinatus tendinitis
In a review o 13 RCTs by Schellingerhout et al. (2008) 5/13 studies ailed to report inclusion criteria (physical examination f ndings), 3/13 studies used Cyriax classif cation, 3/13 studies’ inclusion criteria included increasing pain with abduction, 2/13 studies used pain ul arc sign as inclusion actor
Rotator cu tear
Poor detail o inclusion/exclusion criteria with all 4 RCTs reviewed by Schellingerhout et al. (2008)
Shoulder instability including terms such as voluntary, traumatic, unidirectional, multidirectional, bidirectional
Comparison o our classif cation methods on 168 patients led to diagnosis o ‘multidirectional instability’ between 1.2% to 8.3% dependent on classif cation system used; based on result o laxity testing range o diagnosis or MDI was 8.3% to 82.7% (McFarland et al. 2003) Kuhn (2010) identif ed 17 di erent classif cation systems o glenohumeral joint instability noting an absence o clear def nition, a ‘great amount o discordance’ and ‘di erent eatures’ used in the variety o systems reviewed. Kuhn (2010) presented a urther classif cation system
been made. Most classi cation systems have evolved from the pathoanatomical model such as those pro posed by Cyriax (1982), Neer (1983), Waris et al. (1979), Viikari Juntura (1983), Silverstein (1985), McCormack et al. (1990), Uhthoff & Sarkar (1990), ICD -10 (WH O 2010) and Palmer et al. (2000). Unfortunately, even in the presence of clearly de ned operational de nitions and criteria for inclusion of a patient to a discrete diagnostic category, studies of the proposed classi cation systems have demon strated unsatisfactory levels of inter rater reliability in all but two papers (Liesdek et al. 1997, Bamji et al. 1996, de Winter et al. 1999, Walker Bone et al. 2002, Norregaard et al. 2002, Pellecchia et al. 1996, Palmer et al. 2000, H ayes & Peterson 2003, H anchard et al. 2005). O ther methodological shortcomings of these classi cation systems have been reported including a failure to be comprehensive and failure of classi ca tion categories to be mutually exclusive (Buchbinder et al. 1996; de Winter et al. 1999). In recognition of 14 8
these ndings the development of a reproducible classi cation system for shoulder disorders has been considered a research priority by numerous authors, including Kromer et al. (2010), Braun & H anchard (2010), Kuhn (2010), Mitchell et al. (2005), G reen et al. (2008), Schellingerhout et al. (2008), G reen et al. (2003) and Buchbinder et al. (2003) to name but a few. The variability in diagnostic classi cation should raise signi cant caution when interpreting results from studies which seek to investigate these labelled disorders. Furthermore, comparison of studies which seek to investigate treatment effects for a given group of patients is extremely dif cult if not impossible to ascertain because of the heterogeneity (broad range of different pathologies) in the samples studied. Recognition of the contemporary issues relating to diagnosis and classi cation of shoulder conditions, appears to continue to support Mait land’s acknowledgment in his seminal work more
Th e d ia g n o s is a n d d ia g n o s tic title s o f s h o u ld e r c o n d itio n s
than 40 years ago of the dif culties, limitations and obstructions should management decisions be based on the diagnostic title alone. When evaluating the literature, several reasons become apparent which help to explain most of the current issues surrounding the lack of uniform ity of diagnosis and dif culties establishing links between shoulder pathology and clinical decisions regarding treatment. Issues relating to the use of terminology, physical examination procedures, imaging modalities, criterion standards, current understanding of pathologies and the complexity of problems around the shoulder are explored and discussed further.
P hys ic a l e xa mina tion re la te d to the d iffe re ntia l me d ic a l d ia gnos is of s hould e r c ond itions Diagnostic accuracy – a brief review Prior to reviewing the current evidence relating to the diagnostic accuracy of tests relating to
shoulder conditions it is pertinent to brie y review the concepts and statistical tests associated with diagnostic test accuracy. Six of the most commonly used statistics are detailed in Table 4.2. Diagnostic accuracy studies seek to compare the test of interest with a reference standard, the criterion which best de nes the condition that is being assessed. For example, tests which seek to identify the presence of a rotator cuff tear would be best compared against a reference standard such as the observation of the involved rotator cuff tendon during surgery. The reference standard should have proven criterion validity – a measure already held to be valid. As will be dis cussed in relation to shoulder conditions some of the reference standards commonly used are yet to be fully validated which means caution is required when interpreting results from diagnostic accuracy studies. Furthermore, when considering diagnostic accu racy studies, bias can signi cantly in ate the diagnostic value of a test. It is essential that the
Table 4.2 Some o the more common statistical concepts associated with def ning the accuracy o diagnostic tests
Statistic
Description
Values
Other comments
Sensitivity
True positive rate Ability o test to identi y a positive f nding when the condition is present The probability that a patient with the disease will have a positive test result Help ul or ruling out a condition i.e. a test that has a high sensitivity, helps rule a condition out when the test result is negative
Range 0–1 (0–100%) As result gets closer to 1, certainty that a negative result rules out the presence o the condition increases
Use ul to rule out a condition ‘SnNOut’ mnemonic – a test with a high sensitivity proves use ul to help rule out the presence o a condition when the result rom the test is negative
Specif city
True negative rate Discriminative ability o test to identi y i the condition is absent when it truly is absent The probability that a patient without the disease will have a negative test result Help ul or ruling in the presence o a condition i.e. a test that has a high specif city helps rule in a condition
Range 0–1 (0–100%) As result gets closer to 1, certainty that a positive test result rules in the presence o the condition
Use ul to rule in a condition “SpPin’ mnemonic – a test with a high specif city proves use ul to help rule in the presence o a condition when the result rom the test is positive
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Table 4.2 Some o the more common statistical concepts associated with def ning the accuracy o diagnostic tests—cont’d
Statistic
Description
Values
Other comments
Positive likelihood ratio
Use when a test result is positive to provide a quantitative estimate that the condition is present The increase in the odds o having the disease a ter a positive test result
The higher the value, the greater the certainty that the positive result indicates the presence o the condition
+LR >10 O ten conclusive increase in likelihood o condition +LR5–10 Moderate increase in likelihood o condition +LR 2–5 Small increase in likelihood o condition +LR 1–2 Minimum increase in likelihood o condition +LR 1 No change in likelihood o condition
Negative likelihood ratio
Use when a test result is negative to provide a quantitative estimate that the condition is absent The decrease in the odds o having the disease a ter a negative test result
The lower the value, the greater the certainty that the negative test result indicates the absence o the condition
−LR 1 No change in likelihood o condition −LR 0.5–1 Minimum decrease in likelihood o condition −LR 0.2–0.5 Small decrease in likelihood o condition −LR 0.1–0.2 Moderate decrease in likelihood o condition −LR <0.1 O ten conclusive decrease in likelihood o condition
Pretest probability
The clinician’s estimate o a patient having a condition given all the available in ormation be ore a diagnostic test is per ormed. Pretest probability means putting a number on this estimate Considerations include the prevalence o the condition in the patient’s pool and specif c in ormation about the individual patient, i.e. risk actors or the condition
Expressed numerically in the range 0–1 (0–100%), i.e. 100% certain the patient has the condition
Post-test probability
The clinician’s estimate o a patient having a condition given all the available in ormation and with the additional result rom a diagnostic test In other words does the result rom the diagnostic test change the clinician’s mind about the presence or absence o a condition? Dependent upon the sensitivity and specif city values o the diagnostic test
Expressed numerically in the range 0–1 (0–100%), i.e. 100% certain the patient has the condition
15 0
Example: Consider the situation where a clinician is uncertain regarding the presence o a condition in a patient on the basis o the history, signs, symptoms, demographics, etc. – the pretest probability is 50% or 0.5. I a diagnostic test possesses a high sensitivity and specif city then the results rom the test will result in a large change rom the pretest probability value to the post test probability value. E.g. Apost-test probability 90% (0.9) – i.e. an uncertain clinical situation regarding the presence o a condition is changed to a clinical situation where the clinician can be relatively certain o the presence o the condition
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quality of individual diagnostic accuracy studies in systematic reviews is undertaken and several quality assessment tools have been devised including the Q UADAS (Q uality Assessment of Diagnostic Accu racy Studies) (Whiting et al. 2003) and STARD (Standards for the Reporting of Diagnostic Accuracy Studies) (Bossuyt et al. 2003). Several systematic reviews of shoulder tests, the details of which are provided in following sections, have used such meas ures of quality.
Diagnostic accuracy of physical tests In the evaluation of shoulder pain numerous physi cal examination orthopaedic special tests have been reported in the literature, which aim to differen tially diagnose pathologies of the shoulder. For interested readers, Tennent et al. (2003ab) produced a detailed descriptive two article review of these ‘special tests’ presenting them as described by the original authors. The diagnostic utility (use fulness) of these orthopaedic special tests has been an area of relatively high publication rate in recent years. In a recent, rigorous systematic review with meta analysis of individual physical examination tests of the shoulder, H egedus et al. (2008) critiqued 45 diagnostic accuracy studies. With respect to pathoanatomical diagnoses including impinge ment, rotator cuff integrity, glenoid labrum or long head of biceps pathology, instability and acromio clavicular pathology, there appear very few ortho paedic special physical tests that are diagnostically discriminatory. These results are supported by nd ings from other recent systematic reviews of the diagnostic accuracy of physical examination tests of the shoulder, including Beaudreuil et al. (2009), H ughes et al. (2008) and Lewis and Tennent (2007) with respect to rotator cuff pathology, and Dessaur and Magarey (2008), Walton and Sadi (2008), Calvert et al. (2009), Jones and G alluch (2007), Mirkovic et al. (2005) and Munro and H ealy (2009) with respect to pathology of the glenoid labrum. As a general feature the tests appear to possess either high sensitivity/ low speci city or low sensitivity/ high speci city thereby compromising their diagnostic utility. Similar ndings were reported with regard to the reliability of these orthopaedic special physical examination tests in a recent systematic review of 36 studies by May et al. (2010). May et al. (2010) concluded that none of the tests reached an acceptable level of reliability. Appraising the overall literature the authors stated that evidence regarding the reliability
of these physical examination tests of the shoulder was contradictory (May et al. 2010). Furthermore, there is apparent poor reproducibility of results between studies and a general trend to suggest that as the methodological quality of the trial improves, the results relating to the diagnostic accuracy of the special orthopaedic physical tests worsens. Numerous methodological shortcomings have been identi ed with regard to this literature base including small sample sizes, use of inappro priate reference tests and bias. In particular, it is pertinent to note that in the systematic review by H egedus et al. (2008) only two of the 44 studies included which investigated the diagnostic utility of special orthopaedic physical tests were ade quately powered (suf cient sample size) to detect high speci city and sensitivity values.
Rotator cuff integrity and diagnosis based on physical examination tests In respect to rotator cuff integrity, no tests demon strated likelihood ratios to a satisfactory level to modify the post test probability of diagnosing a rotator cuff tear by a moderate or large amount, thereby questioning their clinical utility (H egedus et al. 2008) (see Table 4.2 for a description of statistical terms). At best, based on results from one underpowered and poorly designed study (Walch et al. 1998), H ornblower’s sign may be diagnostic of ‘severe degeneration or absence of the teres minor muscle’ and the external rotation lag sign diagnostic of an ‘infraspinatus muscle tear’ (Fig. 4.2). The bear hug and belly press tests may assist ruling in a subscapularis tear (speci city 0.98), based on results from a well designed but underpowered study (Barth et al. 2006) (Fig. 4.3). Similar ndings were reported by H ughes et al. (2008) in a further systematic review of the diag nostic utility of physical examination tests to detect rotator cuff pathology. Slightly more promising results were reported in a single good quality study undertaken by Park et al. (2005) (Q UADAS score 10/ 14) included in the meta analysis by H egedus et al. (2008). Park et al. (2005) used stepwise logistic regression analysis (a statistical method for making predictions of an outcome) and determined that if a patient was more than 65 years of age, and presented with a positive drop arm sign and tested weak with the ‘infraspinatus test’ or external rotation lag sign (Fig. 4.4), the likelihood of a rotator cuff tear was >90%, with 28% likelihood of a full thickness tear. 15 1
Fig ure 4.2 • Hornblower’s sign (Walch et al. 1998). With the arm in 90° scapular elevation and 90° elbow exion, add resisted external rotation o the arm. Positive test = an inability to externally rotate the arm.
A
B
Fig ure 4.3 • Belly press test (Gerber et al. 1996). In sitting the patient exerts pressure against the abdomen A with or B without the therapist’s hand in between whilst moving the elbow orwards to increase the internal rotation. Positive test = weakness demonstrated by the elbow dropping back.
A
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Fig ure 4.4 • External rotation lag sign (Hertel et al. 1996). A External rotation lag sign – in sitting, the elbow is passively exed to 90°, and the shoulder is held at 20° scapular elevation and near maximum external rotation. B The patient is then asked to actively maintain the position o external rotation as the therapist releases the wrist while maintaining support o the limb at the elbow. Positive test = when a lag or angular drop occurs.
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Impingement and diagnosis based on physical examination tests In their systematic review with meta analysis, H egedus et al. (2008) considered studies investigat ing the biomedical diagnostic term of ‘shoulder impingement’ against a reference standard of tissue pathology thought to be associated with the concept including ‘subacromial bursitis or tendonitis’ or a ‘partial rotator cuff tear’ identi ed at surgery or with the magnetic resonance imaging modality. Unfortunately, meta analysis was only possible on two tests (Neers and H awkins–Kennedy, Fig. 4.5) due to a lack of statistical homogeneity (comparing like with like). Results showed that neither test had suf cient diagnostic utility. Based on the results from a single study, Park et al. (2005) report that at best the supraspinatus/ empty can (Fig. 4.6) or infraspinatus tests may help con rm an impression of impingement due to higher speci city values (0.82 and 0.84 respectively). Lower sensitivity values (0.53 and 0.51) questions their clinical usefulness as screening tests. The validity of the use of the identi cation of tissue pathology as a reference standard for shoulder impingement is open to question given results from studies such as Frost et al. (1999) and Birtane et al. (2001), discussed further in the section ‘Subacromial impingement and imaging’. Caliş et al. (2000) used an alternative reference standard in their study of 120 patients with shoulder
Fig ure 4.5 • Hawkins–Kennedy test (Hawkins & Kennedy 1980). Support the arm in 90° elevation with 90° o elbow exion and orcibly internally rotate the arm. Positive test = pain reproduced in the subacromial space area.
pain to identify the presence of ‘subacromial impingement syndrome’, namely the subacromial injection test (SIT). Caliş et al. (2000) considered a diagnosis of subacromial impingement in patients who reported ‘marked relief of pain and almost total improvement in passive and/ or active range of movement (RO M) values 30 minutes after injec tion’ with an absence of calci c lesions identi ed on radiograph. Results demonstrated that the physical tests either possessed high sensitivity and low spe ci city (i.e. H awkins–Kennedy – sensitivity 92.1%, speci city 25%) or low sensitivity and high speci city (i.e. painful arc – sensitivity 32.5%, speci city 80.5%) thereby compromising their diagnostic accu racy and utility. Considerations regarding the SIT as reference test for subacromial impingement syn drome are discussed in the section on ‘Diagnosis of shoulder conditions based on physical examination tests’.
Glenoid labrum pathology and diagnosis based on physical examination tests O f special orthopaedic physical tests purported to be able to diagnose pathology of the glenoid labrum, individual studies have demonstrated promising results of some physical examination tests, only to be confounded by poor reproducibility of the results by different authors under more stringent condi tions. Numerous systematic reviews including those undertaken by Walton and Sadi (2008), Calvert
Fig ure 4.6 • Empty can test (J obe & J obe 1983). With the arm in 90° scapular elevation and ull internal rotation the patient is asked to resist downward pressure. Positive test = pain and/or weakness. 15 3
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et al. (2009), Mirkovik et al. (2005), Munro and H ealy (2009), H egedus et al. (2008) and Dessaur and Magary (2008) all conclude that at present there are no good single physical examination tests that are able to accurately diagnose the presence or absence of a SLAP (superior labrum anterior
posterior) lesion. Some examples are demonstrated in Figures 4.7–4.10. O ne method used to improve the accuracy of clinical diagnostic physical examination tests is to combine them into clusters. Such an approach has been reported in other body regions with
Fig ure 4.7 • O’Brien’s active compression test (O’Brien et al. 1998). In 90° rontal elevation, 15° horizontal adduction and ull internal rotation, resisted elevation is applied. The test is then repeated with the palm ully supinated. Positive test = i deep pain or a click within the glenohumeral joints is elicited during the f rst manoeuvre, and reduced or eliminated with the second.
Fig ure 4.8 • Biceps load I test (Kim et al. 1999). In supine with the arm in 90° abduction the arm is externally rotated and the orearm supinated. The patient is then asked to ex the elbow while resisting the elbow exion by the therapist. Positive test = i resisted elbow exion is pain provocative.
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Fig ure 4.9 • Biceps load II test (Kim et al. 2001). In supine with the arm in 120° abduction the arm is externally rotated and the orearm supinated. The patient is then asked to ex the elbow while resisting the elbow exion by the therapist. Positive test = i resisted elbow exion is pain provocative.
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Fig ure 4.10 • Crank test (Lui et al. 1996). With the arm in elevation and 90° elbow exion an axial load is applied to the arm while the arm is internally and externally rotated and circumducted. Positive test = pain, catching or clicking.
more positive tests increasing the likelihood of the presence of a given disorder (Laslett et al. 2005, Cook et al. 2010). Results from a single study of such an approach for clinical testing of the glenoid labrum (SLAP), unfortunately has failed to demon strate any more impressive results (G uanche & Jones 2003). Positive results from combinations of two or three tests had the effect of only small increases in speci city but consequently reduced the sensitivity values of a single test. Further studies into such an approach are clearly required before any conclusions about the usefulness of combinations of physical tests for identifying SLAP lesions in clinical practice are made.
Shoulder instability and diagnosis based on physical examination tests Results from diagnostic accuracy studies investigat ing the concept of instability appear more promis ing. Although there was insuf cient data to perform meta-analysis, H egedus et al. (2008) suggest that the apprehension (Fig. 4.11), relocation (Fig. 4.12) and anterior release tests (Fig. 4.13) are useful to diagnose anterior instability, especially when appre hension as opposed to pain is considered as the
nding to indicate a positive test. A similar conclu sion is reached by Fisher and Dexter (2007).
Acromioclavicular joint conditions and diagnosis based on physical examination tests With regard to acromioclavicular joint pathology, again H egedus et al. (2008) report of insuf cient power to undertake meta analysis. None of the tests studied appeared clinically valuable based on likelihood ratios. Suggestion was made that due to high sensitivity values (0.96) (Walton et al. 2004), an absence of pain on palpation of the acromiocla vicular joint may prove bene cial as an exclusion test of acromioclavicular joint pathology. Results relating to the active compression test, although appearing promising, are confounded by results which indicate worsening of the diagnostic utility of the test as the methodological quality of the studies improve (H egedus et al. 2008).
Frozen shoulder diagnosis based on physical examination tests Restriction of passive movement of the shoulder, particularly lateral rotation is necessary to assist in 15 5
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Fig ure 4.11 • Apprehension test (Rowe & Zarins 1981). In supine passively rotate the arm into maximum external rotation in 90° abduction and apply a posteroanterior orce to the humeral head. Positive test = apprehension to the movement with or without pain.
Fig ure 4.12 • Relocation test (J obe et al. 1989). Repeat the apprehension test with a posterior directed orce on the humeral head. Positive test = an increase in the external rotation range be ore symptom/ apprehension reproduction.
Fig ure 4.13 • Anterior release test (Gross & Diste ano 1997). Repeat the relocation test and at the limit o external rotation release the posterior directed orce. Positive test = a eeling o apprehension with or without a sudden pain.
the diagnosis of frozen shoulder (Bunker 2009, H anchard 2011). A recent review by H anchard et al. (2011) reported that reliability measuring lateral rotation using visual estimation, re ective of most clinical practice is dif cult. H anchard et al. (2011) cited evidence from studies including those by Croft et al. (1994) who found that visual esti mation of external rotation range of movement was poorly reproducible between six experienced rheu matology primary care physicians (ICC 0.43), and Terwee et al. (2005) who demonstrated that a change of 35° or more of lateral rotation was required to establish between tester agreement of 15 6
two physiotherapists. It must also be recognized that the clinical sign of restriction of shoulder exter nal rotation is not exclusively a feature of frozen shoulder but also of other shoulder conditions (i.e. osteoarthritis). The diagnostic considerations of frozen shoulder and the other conditions described in this section are discussed in the section ‘Sum maries of the most common shoulder disorders’.
Diagnosis of shoulder conditions based on physical examination tests – an appraisal Numerous issues have been reported in the literature which may help explain the disappointing diagnostic
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accuracy and reliability of these orthopaedic physical examination tests and it is perhaps pertinent at this point to discuss brie y some of the ndings. Anatomical basis – G reen et al. (2008) sought to review systematically the literature relating to the common clinical tests for the shoulder to establish whether a valid anatomical basis for the test has been established and whether it supported the conceptual theory on which the tests were developed. O f 34 orthopaedic special tests identi ed in the literature search only six had been studied with respect to anatomical validity, highlighting the dearth of investigation into theory on which the tests were developed. Interestingly, in this review only four orthopaedic special tests (active compression (O ’Brien’s test), shoulder quadrant, lift off test and H awkins–Kennedy manoeuvre) were identi ed with a degree of consensus to have a valid anatomical basis. Furthermore, Tucker et al. (2011) in a pilot study on one cadaver investigated the anatomical validity of the H awkins–Kennedy test. This study failed to demonstrate evidence of supraspinatus compression within the subacromial space, which was the proposed mechanism by the original authors (H awkins & Kennedy 1980). In contrast, Tucker et al. (2011) found evidence to suggest that the long head of biceps brachii and the rotator cuff interval, structures which are rarely implicated in impingement syndrome, were compressed. These ndings are broadly consistent with the results of Yamamoto et al. (2009) who, in addition, also found the subscapularis tendon to be compressed during the H awkins–Kennedy test. Face validity – The face validity of orthopaedic special tests which seek to selectively stress individual tendons of the rotator cuff has also been disputed, given the anatomical interdigitation and con uence of the rotator cuff tendons (Lewis 2009, Burkhart et al. 1993, Clark & H arryman 1992). Pain inhibition – Studies by Ben Yishey et al. (1994), Steenbrink et al. (2006), Park et al. (2008) and Cordasco et al. (2010) have all demonstrated signi cant increases in muscle strength around the shoulder complex in subjects with a variety of diagnoses including full thickness rotator cuff tears, partial thickness rotator cuff tears and impingement syndrome following the
administration of a subacromial local anaesthetic injection. These ndings demonstrate the signi cant inhibitive effect pain has on the ability to generate muscle force in the shoulder and therefore challenges the face validity of physical examination procedures which purport to implicate the integrity of a speci c muscle or tendon through strength testing. Pain source – In a review article, Lewis (2009) acknowledges the evidence which appears to implicate the subacromial bursa as a potential source of shoulder pain. Work from authors such as G otoh et al. (1998, 2002), Sakai et al. (2001), Voloshin et al. (2005) and Santavirta et al. (1992) have demonstrated a positive correlation between shoulder pain and levels of proin ammatory cytokines and the neuropeptide substance p contained within the subacromial bursa. Naredo et al. (2002) and similarly Lewis (2009) contend that many orthopaedic special tests which purport to differentially assess the rotator cuff tendons, subacromial bursa and subacromial space will lead to mechanical stimulation of the subacromial bursa and hence the nociceptors within. A positive pain response may therefore merely represent stimulation of the subacromial bursa as opposed to the selective structure the test is purported to stress and therefore lead to poor speci city of the examination procedure and inability to make a speci c diagnosis. O perational def nitions – H anchard et al. (2011) discuss how unclear operational de nitions when assessing shoulder range of movement may affect both the intra rater and inter rater reproducibility of results. Considerations such as determination of the end point of range of movement, that is, onset, increase or where pain becomes intolerable, patient positioning during the assessment of range of movement and whether external stabilization of the trunk or scapula is provided are such factors (H anchard et al. 2011). A lack of clarity with regard to the speci c performance and interpretation of results (operational de nitions) of the other physical tests discussed in this section must also be considered. Re erence test – As discussed, diagnostic accuracy studies seek to compare a given test against a reference standard. Many of the physical tests reported in the preceding sections have used observed ndings at shoulder arthroscopy or 15 7
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imaging ndings as the reference standards. As Mohtadi et al. (2004) note, the validity of surgical ndings at arthroscopy is yet to be rmly established and additional research is required to determine the accuracy and reliability of ndings at arthroscopy. Similar work remains to be undertaken with regard to imaging modalities including MRI and ultrasound. Furthermore, the use of pathoanatomical reference tests may not be the ideal choice as the relationship between pain and tissue pathology in shoulder conditions remains unclear given the high presence of asymptomatic tissue lesions in shoulder investigations. Subacromial impingement as a clinical presentation also fails to possess a gold standard with which to compare physical examination tests. Some of the pertinent issues in respect of the use of imaging are discussed in the section ‘Subacromial impingement and imaging’. The use of a subacromial injection test as a criterion measure is also open to problems as it is reliant on the accuracy of the injection and the anatomical integrity of the subacromial or subdeltoid bursa and the glenohumeral joint.
Medical diagnosis of shoulder conditions based on physical examination tests – a summary It is evident that at this stage in scienti c enquiry, physical examination tests which seek to evaluate the shoulder with regard to identifying pathoana tomical structural diagnosis are abound with uncer tainty. In the majority of cases they appear to fail to demonstrate satisfactory diagnostic accuracy and reliability to make a discriminative diagnosis for which the tests were intended. This evidence pro vides the explanation for the unsatisfactory levels of inter rater reliability of classi cation systems pro posed based on a pathoanatomical model. Further more, the lack of uniformity of diagnostic labels on which management decisions are made is problem atic as commonly patients are put into diagnostic groups based on the results of these special orthopae dic tests. There is an obvious need for further meth odologically robust studies in the eld of diagnostic accuracy of physical examination tests in shoulder conditions given the generally poor quality of the current literature base (H egedus et al. 2008, Fisher & Dexter 2007, Beaudreuil et al. 2009, H ughes et al. 2008, Dessaur & Magarey 2008, Mirkovic et al. 15 8
2005, Munro & H ealy 2009). It is clear, therefore, that clinical decision making regarding the conserva tive management of an individual with shoulder pain which is based on a clinical diagnosis and use of diag nostic labels arrived at using special orthopaedic tests is awed. In recognition of these problems, several authors suggest a different model of assessment and treatment be considered, with abandonment of the diagnostic biomedical pathological model in conserv ative care (Lewis 2009, H ughes et al. 2008, May 2010, Schellingerhout et al. 2008). In contrast to the biomedical model and perspec tive of diagnosing tissue pathology to determine management decisions, diagnosis within physiother apy, which guides the prognosis and intervention strategies for patients, is considered at the level of impairments, functional limitations and abilities or disabilities (World Confederation of Physical Therapy (WCPT 2007). The requirement for such an impairment based approach in the management of shoulder conditions is clear when considering the discussion in this and the next section ‘Imaging and the diagnosis of shoulder conditions’. It is interesting to note some of the recommendations in the recent literature with regard to shoulder conditions. H ughes et al. (2008) have stated, ‘perhaps clinicians should be describing signs and symptoms and speculating on pathology rather than trying to localize a speci c pathologic structure’. Lewis (2009) proposes a model which helps the ‘clinical decision making process’ with regard to a patient’s conservative treat ment based on a patient’s clinical response (symptom modi cation) to a variety of manual therapy tech niques applied to the components of the shoulder complex, cervical and thoracic spine. It is particu larly interesting to note how this contemporary stance appears to mirror the contention that Mait land arrived at more than 40 years ago, recognizing the problems associated with diagnosis and diagnos tic titles. Maitland’s concept allowed the clinician to base intervention on clinical evidence, i.e. ‘the primacy of clinical evidence’. A quote from Maitland – ‘by basing treatment on symptoms and signs useful treatment may be effected while the medical profes sion and its scientists continue to work towards understanding more in regard to diagnostic titles’ – appears as valid today as the date when Maitland rst developed his concept. A reinterpretation and redef inition of the special orthopaedic tests with respect to the Maitland Concept and their applicability to physiotherapy practice is proposed in the section on orthopaedic special tests on page 223.
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Summary: phys ical examination relating to biomedical diagnos tic titles •
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Numerous s pecial orthopaedic phys ical examination tes ts have been developed which aim to differentially diagnos e pathologies of the s houlder Several s ys tematic reviews and meta-analys es have examined s tudies that have res earched the us efulnes s of thes e tes ts to differentially diagnos e s houlder pathologies In general the tes ts appear to pos s es s uns atis factory reliability, poor reproducibility of res ults between different inves tigators , and demons trate wors ening diagnos tic accuracy as the methodological quality of the s tudies improves A number of is s ues may explain the broadly dis appointing res ults , including the lack of an anatomical bas is on which the tes ts are bas ed, ques tionable face validity of s ome tes ts , the effect of pain inhibition on tes ts as s ociated with s trength as s es s ment, ques tionable reference tes ts and operational de nitions and poor methodological quality of s tudies
Imp lic a tions for p hys iothe ra p is ts •
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Clinical decis ion making regarding the phys iotherapy management of an individual with s houlder pain which is bas ed on a clinical diagnos is derived from the us e of s pecial orthopaedic tes ts is awed Phys iotherapy management s hould be directed towards addres s ing impairments cons idered to be linked to an individual’s functional limitations and dis abilities , rather than to broad biomedical diagnos tic titles A reinterpretation and rede nition of the orthopaedic s pecial tes ts with res pect to the Maitland Concept, the brick wall model and applicability to phys iotherapy practice is dis cus s ed on page 223
Ima ging a nd the d ia gnos is of s hould e r c ond itions The use of imaging in the diagnosis of shoulder conditions The use of radiological imaging modalities to improve the ability to reach a structural diagnosis or as a criterion standard for which to correlate ndings from the physical examination brings with it many considerations which need to be acknowledged
when examining the problems associated with the medical diagnosis and diagnostic labels in shoulder conditions. Similar considerations need to be acknowledged with respect to surgical ndings. The presence of abnormal morphology in asymp tomatic individuals, anatomical variants which are clinically irrelevant, reporting error, inability of imaging to detect clinically signi cant pathology and technical factors have all been reported as explana tion to signify caution when interpreting ndings from radiological investigation (Khan et al. 1998).
Rotator cuff integrity and imaging Results from a variety of studies suggest that both ultrasonography (USS) and magnetic resonance imaging (MRI) are accurate in the diagnosis of full thickness rotator cuff tears with pooled sensitivity values of 0.95/ 0.89 and speci city values of 0.96/ 0.93 respectively, with no statistically signi cant difference between the two imaging modalities (O ttenheijm et al. 2010, Shahabpour et al. 2008, de Jesus et al. 2009). For the detection of partial rotator cuff tears, accuracy is much lower. Pooled sensitivity values of 0.72 and speci city values of 0.93 for ultra sound have been reported, indicating that ruling out a partial thickness tear using this modality may be dif cult (O ttenheijm et al. 2010). Similar results have been reported with respect to the ability of MRI to detect partial thickness rotator cuff tears (sensitivity 0.64/ speci city 0.92) in a meta analysis undertaken by de Jesus et al. (2009). Again no statistically signi cant differences were found between the MRI and USS for the detection of partial thick ness rotator cuff tears. Combining MRI with gado linium enhanced arthrography improves the ability to detect partial rotator cuff tears (sensitivity 0.86/ speci city 0.96) (de Jesus et al. 2009). Important considerations must however be acknowledged when interpreting these ndings. Numerous authors have demonstrated the presence of a variety of pathoanatomical features using a variety of imaging modalities in shoulders of asymp tomatic individuals. Using magnetic resonance imag ing (MRI) Sher et al. (1995) reported an overall prevalence of rotator cuff tears of 34% in 96 asymp tomatic individuals. The frequency of tears increased signi cantly with age, with a prevalence of 54% in those individuals aged over 60 years (28% full thick ness, 26% partial thickness tears). In those individu als aged 19–39 none had a full thickness tear and only 4% had a partial thickness tear. Similar ndings have been reported by Milgrom et al. (1995), 15 9
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Templehof et al. (1999), Worland et al. (2003) and Yamaguchi et al. (2006) utilizing ultrasonography. In asymptomatic individuals aged over 50, full thick ness rotator cuff tears have a reported incidence of 40% (Worland et al. 2003), and a 50% prevalence of a combination of partial and full thickness tears (Milgrom et al. 1995). All these studies have reported a high correlation between increasing age and the presence of rotator cuff tears (either partial or full thickness), regarded by some authors as part of the ‘natural ageing process’ (Worland et al. 2003) or ‘normal degenerative attrition, not necessarily causing pain and functional impairment’ (Tempelhof et al. 1999). Lewis and Tennant (2007) eloquently conclude ‘there is good evidence that both ultra sound and MRI are accurate at identifying full thick ness tears in the rotator cuff and to a lesser extent diagnosing partial thickness tears. H owever the sig ni cance of these ndings is open to interpretation as neither of the imaging modalities is capable of detecting a symptomatic tear from a tear not associ ated with pain or functional loss’.
Subacromial impingement and imaging Subacromial impingement syndrome is classically described as an abnormal contact and compression of the rotator cuff, long head of biceps and subac romial bursa within the subacromial space (Bigliani & Levine 1997, Neer 1983). Current opinion sug gests a vast array of possible causes which have been broadly grouped into intrinsic and extrinsic factors and further classi ed as of either primary or secondary etiology (Bigliani & Levine 1997) (see Table 4.4). As such, subacromial impingement syn drome encompasses a wide spectrum of possible pathologies with different aetiologies and has been considered by some authors to represent a clinical presentation as opposed to a diagnosis (Mohtadi et al. 2004). MRI as an imaging modality provides only a static evaluation of the shoulder and as such is only able to provide an indirect suggestion of subacromial impingement based on the presence of pathology thought to be associated with the diagnosis such as subdeltoid or subacromial bursitis, rotator cuff tend inopathy and/ or rotator cuff tears (Bureau et al. 2006; Birtane et al. 2001). Studies by Frost et al. (1999) and Birtane et al. (2001) demonstrate some of the potential problems with MRI and the diag nostic label of subacromial impingement. Lesions of the rotator cuff, especially supraspinatus, are widely believed to be associated with the clinical signs of 16 0
impingement of the shoulder (Neer 1983, Iannotti 1991; Tan 1998). In a study of 42 patients with, and 31 age matched individuals without signs of subac romial impingement (diagnosed clinically), Frost et al. (1999) demonstrated that 55% of subjects in the symptomatic group and 52% of subjects in the asymptomatic group possessed a pathologic suprasp inatus tendon. As opposed to being related to the clinical sign of impingement, the pathologic suprasp inatus lesions were associated with age. Similar nd ings were reported by Birtane et al. (2001) who used a physiological standard of reference, namely a sub acromial injection of local anaesthetic (lidocaine) to investigate the value of MRI in subacromial impinge ment syndrome. MRI based pathologic ndings of lesions in the rotator cuff demonstrated a high sen sitivity (98.85%) but low speci city (36.84%) in terms of discriminating the subacromial injection test based diagnosis of subacromial impingement syndrome (Birtane et al. 2001). Although open MRI is able to offer dynamic evaluation, limited availability and restriction of evaluation to single plane shoulder motion are cited as limiting factors at the current time (Bureau et al. 2006). Dynamic ultrasonography has also been used to investigate subacromial impingement syndrome, with features such as bunching of the subacromial bursa or pooling of uid in the subacromial bursa purported to represent the subacromial impinge ment (Read & Perko 1998, Bureau et al. 2006, Awerbuch 2008). Unfortunately, the reliability of dynamic ultrasonography is yet to be convincingly demonstrated in the diagnosis of subacromial impingement syndrome (Read & Perko 1998, Bureau et al. 2006; Awerbuch 2008). Furthermore, although MRI and ultrasonography have been reported to demonstrate high diagnostic accuracy in the identi cation of the soft tissue lesions associated with the diagnosis of impingement such as rotator cuff tendi nopathy and tears and subacromial or subdeltoid bursitis, it must be remembered that these patho anatomic features possess a high presence in asymp tomatic individuals. Radiographic evaluation may provide valuable information regarding the presence of features con sidered as potential causes of primary subacromial impingement (acromioclavicular osteoarthritis, os acromiale and acromion morphology). H owever, con icting results have been reported regarding the relevance of such ndings (Michener et al. 2003, Bigliani & Levine 1997, Lewis & Tennant 2007).
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Lesions of the subacromial bursa are often con sidered to be associated with subacromial impinge ment syndrome and as such a possible source of shoulder pain (Bigliani & Levine 1997, Neer 1983). Unfortunately, at the present time, there appears to be a lack of standardization when assessing the status of the subacromial or subdeltoid bursa using ultrasonography (O ’Connor et al. 2005, Awerbuch 2008). Furthermore, bursal changes have been reported with high incidence in the asymptomatic individuals in studies such as Naranjo et al. (2002) using ultrasonography and Zanetti et al. (2000) using MRI. van H olsbeeck and Strouse (1993) have demonstrated that abnormal uid collection within the subacromial bursa may result from communication from the glenohumeral joint in the presence of rotator cuff tear, and therefore has the potential to be as common a nding as asymptomatic rotator cuff tears (Awerbuch 2008). Furthermore, Svendsen et al. (2004) consider that such bursal changes may be physiological re ecting the protective role of the bursa.
Glenoid labrum and imaging Magnetic resonance imaging arthrography has been described as the gold standard imaging modality for identifying labral pathology (Abrams & Safran 2010). Sensitivity values such as 89% (Bencardino et al. 2000) and 82% (Waldt et al. 2004) and speci city values such as 91% (Bencardino et al. 2000) and 98% (Waldt et al. 2004) have been reported. Again however, several studies have illustrated the presence of labral pathology in asymptomatic indi viduals. Increases in signal intensity in glenoid labrum (which has been correlated with histological ndings of brovascular disease, degeneration, calci cation, ossi cation) has been reported in 46% and 50% of normal shoulders (McCauley et al. 1992, Chandnani et al. 1992) and 64% of asymptomatic professional baseball throwers (Miniaci et al. 2002). Features corresponding with a glenoid labral tear have been identi ed in 45% of throwing shoulders and in 36% of non throwing shoulders in asymptomatic profes sional baseball throwers (Miniaci et al. 2002).
Other shoulder structures and imaging Numerous other structural abnormalities have been reported in radiological imaging studies of shoulders of asymptomatic individuals. In an MRI study of 20 asymptomatic overhead athletes, aged 18–38 years (12 college baseball pitchers and eight professional tennis players), Connor et al. (2003) demonstrated
25% of the dominant shoulders to possess MRI evi dence of a Bennett’s lesion (an extra articular ossi cation of the posteroinferior glenoid) compared with none of the non dominant shoulders. Further ndings included joint effusions (90%), subacromial uid (22.5%), sclerotic or cystic changes in the greater tuberosity, tears of the anteroinferior or superior glenoid labrum (7.5%) and rotator cuff tears (partial or full thickness) (40%). Sixteen of the 20 participants were followed up with interview after ve years. During this period none of the ath letes had developed symptoms or required any assessment for shoulder related problems. All had continued to play their sport at a competitive level without any noticeable reduction in ability due to their shoulder.
The limitations of imaging – an appraisal and some considerations A few methodological considerations should be made at this stage. O bviously the inherent limitation in any imaging study of asymptomatic individuals such as those detailed in this section, is the absence of operative or histologic comparison to verify the ndings. H owever, the criterion standard of surgical ndings is also open to contention, as essentially it is reliant on the ability of an observer (surgeon) to determine the pathology identi ed. Kuhn et al. (2007) have demonstrated this contention when assessing the interobserver agreement in the classi cation of rotator cuff tears amongst experienced shoulder surgeons who reviewed a series of arthro scope videos. When distinguishing between full thickness and partial thickness tears interobserver agreement was high (k=0.85). H owever, when clas sifying the depth of partial thickness tears agree ment was poor (k=0.19). Further research to determine the accuracy and reliability of arthro scopic ndings and the diagnosis of speci c shoulder conditions is required (Mohtadi et al. 2004). Findings such as these illustrate the caution required and dif culty when interpreting evidence from radiological imaging studies of shoulder prob lems. As Miniaci et al. (2002) summarized ‘the mere presence of signal changes or abnormalities does not necessarily indicate pathologic symptomatic nd ings’. The high incidence of false positive MRI and ultrasonographic ndings, particularly in those aged over 50 and individuals who place signi cant stress on their shoulders such as throwers, emphasize the dif culties relating pathology identi ed on imaging with the source of symptoms in shoulder conditions. 16 1
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The potential for misdiagnosis or misrepresentation of the source of a patient’s functional problem in shoulder conditions is therefore signi cant. When considering the relationship between radiological imaging ndings and clinical symptoma tology in shoulder conditions it is also interesting to recall Case study 4.1 provided by Maitland (1986) and used to demonstrate his contention urging clini cians to interpret the theoretical aspects of a patient’s condition in a balanced way ‘we must not get diverted by the theoretical aspects of a patient’s dis order such that it is to the detriment of the clinical aspect’ – a further feature of the Concept ‘theory’.
Summary: the us e of imaging in the diagnos is of s houlder conditions •
• •
•
Radiological imaging is us ed to improve the ability to reach a s tructural diagnos is or as a criterion s tandard for which to correlate ndings from the phys ical examination, however: A wide variety of s tructural les ions have been identi ed in the as ymptomatic population Radiological imaging may als o be as s ociated with identifying anatomical variants which are clinically irrelevant, reporting error and inability of imaging to detect clinically s igni cant pathology As Miniaci et al (2002) s ummarized ‘the mere pres ence of s ignal changes or abnormalities does not neces s arily indicate pathologic s ymptomatic ndings ’ and Lewis and Tennant (2007) ‘… there is good evidence that both ultras ound and MRI are accurate at identifying full-thicknes s tears in the rotator cuff and to a les s er extent diagnos ing partial thicknes s tears However, the s igni cance of thes e ndings is open to interpretation as neither of the imaging modalities is capable of detecting a s ymptomatic tear from a tear not as s ociated with pain or functional los s ’
Imp lic a tions for p hys iothe ra p is t •
If res ults from radiological inves tigations are available to read or view, phys iotherapis ts mus t interpret the res ults in a balanced way bearing in mind the s ymbolic permeable brick wall and the primacy of clinical evidence (Maitland 1986)
Surgic a l nd ings – s ome c ons id e ra tions with re ga rd to s p e c i c d ia gnos is Surgical studies also emphasize the dif culty in identifying the relationship between tissue pathol ogy and clinical symptoms reported by patients. 16 2
Cas e s tudy 4 1 Demonstration o the primacy o clinical evidence A 74-year-old healthy lady, who, for s ix weeks , had been unable to comb her hair or reach far enough behind her back to do up her bras s iere becaus e of ‘s houlder weaknes s and dis comfort’, was told that the only options open to her were ‘major s urgery’ or ‘put up with it’ She refus ed s urgery, preferring to put up with it becaus e her s is ter, who ‘had had exactly the s ame problem’ was ‘cured by phys iotherapy’, s he pres s ed for the s ame treatment The diagnos is was ‘marked os teoarthritis ’ She certainly did have gros s joint changes which were obvious both clinically and radiologically Phys ically s he had a 35% reduction in range, pain on s tretching, and cons iderable painles s dry crepitus during active movements When moved pas s ively with the glenohumeral joint s urfaces compres s ed, crepitus was increas ed and dis comfort (not pain) was provoked Prior to the ons et of s ymptoms s ix weeks previous ly, although s he knew s he had an arthritic s houlder, s he did not cons ider s he had any real dis ability The ‘major s urgery’ was bas ed on the radiological ndings which were interpreted academically It would be unlikely that thes e radiological changes had occurred over the s ix-week period In fact, they were more likely to be longs tanding, although her s ymptoms were relatively recent On clinical examination her problem was an ‘end-of-range’ problem rather than a ‘through-range’ (gros s os teoarthritis ) problem Her s houlder res ponded quite s atis factorily by regaining its pre-exacerbation s tate (Maitland 1986)
Indeed, Snow et al. (2009) have acknowledged the paucity of evidence in the literature which has sought to demonstrate a correlation between arthro scopic ndings and patients’ pain. In a series of 55 patients diagnosed with impinge ment syndrome who underwent subacromial decompression (resection of the anterolateral edge of the acromion, release and resection of the cora coacromial ligament from the acromion), Snow et al. (2009) reported that there was no statistically signi cant correlation between the severity of impingement identi ed at arthroscopy with the level of pain reported either pre or postoperatively or the level of postoperative satisfaction (89% sat isfaction). Similarly, Soyer et al. (2003) demonstrated that the amount of acromion resected (thus the severity of impingement) at surgery was not
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related to the level of improvement patients reported postoperatively. Powell et al. (2009) reported that in 98 patients who underwent arthroscopic subacromial decom pression for impingement, no statistically signi cant difference was found in both the pre and postop erative outcome measures between those patients without a rotator cuff tear (n=75) and those with a rotator cuff tear (which was left unrepaired) (n=23). Such results add support to the dif culty in the current level of understanding as to the extent to which a rotator cuff tear contributes or causes symp toms. Such results suggest the source of pain in these patients was multifactorial and not solely related to the tissue pathology identi ed. As part of the research undertaken, Mohtadi et al. (2004) reported the arthroscopy ndings of 58 patients (43 men and 15 women) who presented with shoulder pain consistent with shoulder impinge ment from the clinical examination and whose symptoms had persisted for more than three months and proven resistant to a course of conservative management. Within the inclusion criteria was a more than 50% reduction in pain following injection of local anaesthetic into the subacromial space. Findings at surgery included abnormal tendons, supraspinatus (79.3%), infraspinatus (48.3%), sub scapularis (32.8%) and long head of biceps (66%) including non retracted ruptures in 5.7%. Tendon pathology was further de ned as ‘in amed’, ‘frayed or partially torn’ (in the case of supraspinatus on the bursal or humeral surface) or ‘full thickness tear’ (in the case of the long head of biceps ‘complete rupture’). O ther ndings included pathology of the acromioclavicular joint (56.4%), abnormalities of the glenoid labrum (85.5%), glenoid articular surface (41.1%) and humeral head surface (65.5%). Fur thermore, ndings in ve patients con rmed a diag nosis of either glenohumeral instability as evidenced by the presence of H ill–Sachs ( ve patients), Bankart (three patients) and SLAP lesions (two patients) with or without rotator cuff lesions, despite the study criteria speci cally attempting to exclude patients with a history of instability. Such ndings demonstrate that patients with a given clinical pres entation, in this case features consistent with the concept of impingement, may have a variety of pathologic ndings and concurrent speci c diag noses including those not necessarily associated with the classical concept of extrinsic compression of the rotator cuff. Mohtadi et al. (2004) contend that subacromial impingement is therefore a clinical
presentation as opposed to a speci c diagnosis, a view which is supported by numerous other authors. Indeed, the concept of subacromial impingement, thought to imply compression between the rotator cuff tendons and bursa between acromion and the humeral head has been brought into question through studies which have demonstrated a lack of contact between these two structures (McCallister et al. 2005, G oldberg et al. 2001). Despite the advances with regard to shoulder diagnosis that imaging and arthroscopy have brought, the current understanding of the pathoaetiology of shoulder conditions remains incomplete. In particu lar, the relationship between patients’ pain and tissue level pathology remains unclear, with suggestion that, certainly with regard to patients presenting with a clinical diagnosis of subacromial impingement and pathology of the rotator cuff, the origins of pain are multifactorial and not solely related to mechanical factors. Such evidence lends support to the contention that physiotherapeutic management which is based solely on a presumed pathoanatomical lesion and biomedical diagnostic label is awed and highlights the need for a con ceptual model which acknowledges the potential multidimensional nature of a patient’s condition at the level of the individual, considering their impair ments, functional limitations and associated abilities and/ or disabilities. Again, Maitland’s contention regarding the poten tial dif culties and limitations should physiothera peutic treatment be based on the medical diagnosis alone appears to continue to be as valid today despite the signi cant developments in understanding of pathology relating to shoulder conditions that scien ti c enquiry has made over the last 40 years since the origination of the Maitland Concept.
Summary: s urgical ndings – s ome cons iderations with regard to s peci c diagnos is •
•
Res ults from s urgical s tudies further illus trate that the current unders tanding of the pathoaetiology and pathophys iology of s houlder conditions remains far from complete In particular the relations hip between patients ’ pain and tis s ue level pathology remains unclear, particularly relating to rotator cuff dis orders and glenoid labrum les ions
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The imp a c t of c ha nging knowle d ge on the d ia gnos is of s hould e r c ond itions – a c linic a l e xa mp le re la ting to rota tor c uff te nd inop a thy As discussed, diagnostic labels in shoulder condi tions are often derived from and used to explain the underlying pathology thought to be present which would explain the presenting signs and symp toms of a condition. Unfortunately, at present, despite signi cant advances in shoulder diagnosis there remains a signi cant lack of understanding of pathoaetiology and pathophysiology of shoulder conditions (Lewis & Tennant 2007, Lewis 2009, van der H eijden 1999). As Maitland (1986) acknowledged, ‘within medicine today there is much that is clearly known and understood. There is much that is being discovered day by day as science progresses. Nevertheless, there is still much that is yet unknown. Also, there is a related facet which must be considered – there is much we TH INK we know; yet as medical science progresses it may be proved wrong’. A perfect example of this latter statement in regard to shoulder conditions relates to the under standing of pathology of the rotator cuff, reported to be one of the most common causes of shoulder pain (Lewis & Tennant 2007, Uhthoff and Sarker 1990;, Seitz et al. 2011). The diagnostic label of ‘supraspinatus tendonitis/ tendinitis’ or ‘rotator cuff tendonitis/ tendinitis’ has been widely reported in the literature. This label, in its truest sense is a pathoanatomic term which describes an in amma tory pathologic problem within the structure of the tendon. As such, traditional medical teach ings have deeply entrenched a belief that anti in ammatory treatment and rest will bene t patients with the condition (Khan et al. 2000). Advances in the understanding of the pathology of tendon disorders has, however, led to the demise of the primary in ammatory model with the recognition that the underlying pathology in the rotator cuff and other tendons commonly affected is predominantly tendinosis, a degenerative, non in ammatory condition (Fukuda et al. 1990). Although the pathoaetiology remains unclear, patho logical features of tendinosis have been considered by some as degenerative and others as a failed healing response (Cook & Purdam 2009). This paradigm shift in the understanding of tendon pathology has brought with it important implica tions for management. In recent years the term 16 4
‘tendinopathy’ has been advocated by numerous authors as the clinical diagnostic term of choice, encompassing the combination of pain and impaired performance, without assumption as to the underly ing pathology (Maffulli 1998). With speci c regard to rotator cuff tendinopathy, signi cant developments have been made with regard to our understanding of the aetiology of the condition over recent years. O nce attributed to an intrinsic lesion of the rotator cuff tendons by Codman (1934), later theories by Neer (1972) accredited almost all the pathology in the rotator cuff entirely to direct mechanical irritation and impingement from the undersurface of the acromion due to variations in the shape and slope, inferiorly protruding acromioclavicular osteophytes and changes in the coracoacromial ligament – extrinsic causes. Based on his theories Neer (1972) recommended a surgical procedure, acromioplasty, for those patients whose symptoms persisted despite conservative treatment, which has become one of the most widely used shoulder surgical procedures (Stephens et al. 1998). H owever, in a review by Iannotti (1991) subgroups of patients with unsat isfactory outcomes following acromioplasty were reported (5–50%). Although these results were attributed to inaccurate diagnosis or incomplete decompression, the understanding of the pathoaeti ology of the condition was largely unknown. Since this classic publication by Neer (1972) the aetiology of rotator cuff tendinopathy remains unclear, with numerous authors proposing alternative theo ries involving both intrinsic, extrinsic or a combina tion of both factors, reviewed comprehensively by Seitz et al. (2011), Bunker (2002) and Lewis (2009). Tables 4.3 and 4.4 below summarize the main concepts and evidence presented from work undertaken by Lewis (2009), Seitz et al. (2011), Bunker (2002), Castagna et al. (2010) and Cook and Purdam (2009). These tables serve to dem onstrate some of the arguments made both for and against the aetiology of rotator cuff being due to extrinsic factors (factors which cause compression of the rotator cuff tendons – subacromial impinge ment) or due to intrinsic factors (structural change within the tendon as a result of aging, overuse, etc. such as occurs in other tendons such as the common extensor origin at the elbow, Achilles tendon or patella tendon which are not enclosed within an anatomical space). It is interesting to examine the course of develop ments in the scienti c understanding of rotator cuff
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tendinopathy, particularly relating to the aetiological mechanisms, from a position where all pathology of the rotator cuff was attributed to extrinsic compression (subacromial impingement) (Neer 1972) to the current understanding which suggests that rotator cuff tendinopathy is not a homogenous entity, and also may possess a complex multifactorial aetiology with interplay of both intrinsic and
extrinsic factors. Furthermore, with improved understanding of tendinopathy in other body regions, that is, the Achilles tendon and patella tendon, a growing body of evidence is now building supporting the recognition and importance of intrinsic factors in the development of rotator cuff tendinopathy. Indeed, some authors, including, Baring et al. (2007), summarize that ‘the disease (rotator cuff
Table 4.3 The main theories and concepts relating to extrinsic mechanisms o rotator cu tendinopathy
Rotator cu tendinopathy – supporting evidence o e xtrin s ic mechanisms
Rotator cu tendinopathy – negating evidence o e xtrin s ic mechanisms
Association between acromion shape and severity o rotator cu (RC) pathology is well documented – associated with RC pathology with bursal-sided partial thickness tears and progression to ull thickness RC tears
Presence o anatomical eatures such as acromion shape, AC joint arthritis, subacromial spurs may contribute, but be insu f cient alone to an extrinsic RC tendinopathy mechanism, i.e. predispose to RC tendinopathy? Surgical studies have reported success ul outcomes in patients undergoing rotator cu repair alone without acromioplasty O patients reviewed nine years ollowing acromioplasty surgery, 20% have gone on to develop ull thickness rotator cu tears – this suggests mechanism other than mechanical compression involved These changes are considered by some authors as secondary reactive changes. Considered that the primary lesion develops intrinsically within the rotator cu leading to poor control o the humeral head and secondary impingement between the bursal sur ace o the rotator cu and the acromion
Movement disorders o the scapula have been demonstrated in patients with RC tendinopathy compared to asymptomatic individuals which may cause a relative reduction in the subacromial space, especially with some o the more obvious movement disorders (scapula dyskinesis) Impairments that produce movement abnormalities o the scapula could include so t-tissue restrictions, muscular control def cits and postural def cits
Movement disorders o the scapula which may cause a relative increase in subacromial space have been reported. Some di erences in scapula movement between asymptomatic individuals and subjects with RC tendinopathy are small and question relevance to extrinsic RC compression Methods used to assess and describe scapula movement abnormalities possess unreported reliability The in uence o movement disorders o the scapula on the relative size o the subacromial space remain speculative
Reduction in subacromial space theorized to be reduced through movement disorders o the humeral head and to contribute to compression o the rotator cu Impairments that have been linked to excessive humeral head migration include (a) reduced posterior capsule length, with relationships identif ed between this impairment and patients with RC tendinopathy, (b) RC muscular control def cits
Superior humeral head migration through abnormal movement patterns may be compensated or by changes in scapular movement patterns (a) I a relationship does exist between posterior capsule length, it is likely not to be a contributing actor in all patients with RC tendinopathy, (b) con icting evidence as to the e ects or RC muscular control def cits have been published
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Table 4.3 The main theories and concepts relating to extrinsic mechanisms o rotator cu tendinopathy—cont’d
Rotator cu tendinopathy – supporting evidence o e xtrin s ic mechanisms
Rotator cu tendinopathy – negating evidence o e xtrin s ic mechanisms
Concept o internal impingement which has emerged over the last decade, suggests that the articular sur ace o the rotator cu tendons can be compressed between the articular sur aces o the humeral head and the glenoid and, as such, provide an explanation or the observation o articular sur ace RC tendinopathy Lesions at the articular margin o supraspinatus insertion have been reported to be associated with scu f ng and injury to the posterosuperior labrum in throwing athletes – contact between these two regions during elevation/external rotation Contact between the biceps pulley and the anterosuperior labrum has been reported during elevation/internal rotation in sportsmen Proposed theories as to the cause o this type o impingement include microinstability o the shoulder, posterior capsule restriction, reduced humeral retroversion, scapula movement disorders, SLAP lesions Developed from Lewis (2009), Seitz et al. (2011), Bunker (2002), Castagna et al. (2010) and Cook & Purdam (2009).
Table 4.4 The main theories and concepts relating to intrinsic mechanisms o rotator cu tendinopathy
Rotator cu tendinopathy – supporting evidence o in trin s ic mechanisms
Rotator cu tendinopathy – negating evidence o in trin s ic mechanisms
RC tendinopathy located on the articular side o the tendons, in the absence o pathology on the bursal side o the rotator cu tendons suggests an intrinsic mechanism behind the development to RC tendinopathy
Internal impingement (an extrinsic mechanism) provides an alternative explanation or the presence o articular sur ace RC tendinopathy A small patient group exists where tendon pathology is based on the bursal side o the tendon as opposed to the articular side o the tendon Patients with primarily bursal-sided pathology o the rotator cu have been demonstrated to always be associated with attrition o the acromion and coracoacromial ligament, whereas in patients with primarily articularsided Rc tendinopathy there was an absence o attritional lesions on the acromion; however, again consider – are these secondary reactive changes to the intrinsic lesions within the rotator cu ?
Intrinsic actors result in morphological changes within the tendon structure considered by some as a degenerative process or by others as a result o ailed tendon healing Morphological changes include (a) disorganization o hierarchical structure o collagen with thinner f bres, f bre separation and an abnormally high ratio o type III to type I collagen, (b) increases in ground substance with high concentration o proteoglycans, (c) variation in density o tenocytes, areas o increased numbers with increased protein production and other areas o acellularity, (d) increases in the tendon vascularity (neovascularization), (e) in general an absence o in ammatory cells inf ltrates
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Table 4.4 The main theories and concepts relating to intrinsic mechanisms o rotator cu tendinopathy—cont’d
Rotator cu tendinopathy – supporting evidence o in trin s ic mechanisms
Rotator cu tendinopathy – negating evidence o in trin s ic mechanisms
Histological evidence has demonstrated that microscopic and macroscopic tearing at the articular sur ace o the rotator cu precedes histological changes on the acromion Morphological change within the tendon structure results in a tendon which possesses in erior mechanical properties, less able to cope with tensile or shear loads and consequently susceptible to damage and tears Tendinopathic changes such as those demonstrated in RC tendinopathy are demonstrated in numerous other tendons including the Achilles tendon, patellar tendon, extensor carpi radialis brevis, tendons o the groin, all o which are not contained within a physiological space and there ore are not susceptible to extrinsic compressive orces Animal studies support a mechanical overload aetiology or the development o intrinsic tendon degeneration with changes consistent with human tendinopathy produced in rat supraspinatus tendons ollowing an overuse running programme
Results rom animal studies have demonstrated that greatest tendinopathic changes occurred in rat tendons which were exposed to both overuse and extrinsic compression
Aetiological actors associated with the development o RC tendinopathy include age, poor vascularity, genetic predisposition, mechanical overload
The extrinsic compression o the RC may be the actor that predisposes the tendon to tendinopathic changes
RC tendinopathy with an intrinsic mechanism may a ect the unction o the RC to stabilize the humeral head and thereby predispose to reduction o the subacromial space through superior migration o the humeral head
Reduction in subacromial space theorized to be reduced through movement disorders o the humeral head and to contribute to compression o the rotator cu – an extrinsic mechanism may predispose the RC to tendinopathy
Developed from Lewis (2009), Seitz et al. (2011), Bunker (2002), Castagna et al. (2010) and Cook & Purdam (2009).
tendinopathy) is a purely intrinsically initiated phe nomenon, with the changes in the surrounding structures being a secondary feature’. Intrinsic tendon degeneration is now considered as the prin cipal factor in the development of rotator cuff tears (Seitz et al. 2011, Bigliani & Levine 1997, Castagna et al. 2010, Lewis 2009, Cook & Purdam 2009, Bunker 2002). It is also interesting to consider developments in understanding relating to different types of shoulder impingement, including internal impingement and the recognition that patients may present with a variety of different and concurrent tissue pathological ndings (Castagna et al. 2010, Mohtadi et al. 2004). This developing understanding appears to be re ected in the surgical literature, where surgical
management of rotator cuff tendinopathy is driven by the link between observed tissue pathology (based on imaging and ndings at surgery) and proposed mechanisms. With scienti c understand ing regarding the complexities of rotator cuff tendi nopathy developing, authors such as Castagna et al. (2010) recognize the need to tailor surgical man agement to the individual. Such contentions appear supported in the literature with rotator cuff lesions thought to be attributable to internal impingement being treated surgically with debridement of the rotator cuff with subacromial decompression, con sidered by some authors as contraindicated in this condition. O ther authors have also proposed surgical treatment of other conceptualized mechanisms in internal impingement including stabilization of 16 7
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anterior instability with capsular shift, repair of concurrent SLAP (superior labrum anterior poste rior) lesions (thought to contribute to glenohumeral instability leading to internal impingement), remov ing bone fragments of Bennett’s lesion and release of the posterior capsule in patients where this restriction was considered as the underlying mecha nism producing the internal impingement (Castagna et al. 2010). Conversely, where a rotator cuff lesion is thought to be attributable to an extrinsic lesion subacromial decompression with acromioplasty remains the key component of surgery. Despite these scienti c developments many problems and challenges continue in the under standing of rotator cuff tendinopathy including:
• The controversies and continued lack of understanding of the underlying mechanisms and etiology • The mechanisms of symptom production, especially given the scienti c ndings of a high presence of asymptomatic rotator cuff tendinopathy • The limitations of the physical examination to identify speci c shoulder conditions including rotator cuff tendinopathy not including the proposed subcategorisation of rotator cuff tendinopathy based on the underlying mechanism • Whether subgroups of patients with rotator cuff tendinopathy, which is based on the proposed aetiological mechanism (i.e. intrinsic/ extrinsic/ combined), may respond to different tailored interventions. In recognition of such evidence, decision making in physiotherapy management at this current time should continue not be driven by tissue pathology alone, but rather based on impairments, the key contention in this chapter (Seitz et al. 2011, Castagna et al. 2010). Such an approach supports Maitland’s contention in his development of the Maitland Concept, namely the primacy of clinical evidence. Evidence is building in the literature pro viding assistance as to the relationship between im pairments and clinical outcomes. Examples include work by Burkhart et al. (2003) who demonstrated a 38% reduction in the prevalence of shoulder prob lems in a group of competitive tennis players who addressed restrictions to shoulder internal rotation with daily stretches in comparison to a group who did not stretch. 16 8
Summary: the impact of changing knowledge on the medical diagnos is of s houlder conditions – a clinical example relating to rotator cuff tendinopathy •
As Maitland (1986) acknowledged, ‘within medicine today there is much that is clearly known and unders tood There is much that is being dis covered day by day as s cience progres s es Nevertheles s , there is s till much that is yet unknown Als o, there is a related facet which mus t be cons idered – there is much we THINK we know; yet as medical s cience progres s es it may be proved wrong’
Imp lic a tions for p hys iothe ra p is ts •
Phys iotherapis ts mus t keep abreas t of the developments in the theoretical unders tanding of conditions affecting the s houlder (and other body regions ) (the left s ide of the s ymbolic permeable brick wall) but balance this knowledge with the clinical evidence which takes primacy in the clinician’s decis ion-making proces s es (the right s ide of the s ymbolic permeable brick wall)
Sho ulde r c o nditio ns – a pe rs pe c tive fro m an ESP ro le ESP role practice and the diagnos tic tas k As has been discussed in the preceding sections, the medical diagnosis of patients with shoulder conditions is a complex problem. Features such as severity of pain, chronicity, coexisting pathology, in addition to previously discussed issues relating to the uncertainties associated with orthopaedic special tests, asymptomatic pathology identi ed in a variety of radiological imaging, the common occurrence of multiple coexisting structural pathologies, a lack of uniformity of diagnostic labelling and classi cation systems provide signi cant challenges. Furthermore, the clinical manifestations of pathology may vary widely from individual to individual. Nevertheless, ESPs and physicians have a responsibility to the patient, to establish as speci c a medical diagnosis as is possible in order to guide decisions relating to their management and prognosis.
S h o u ld e r c o n d itio n s – a p e rs p e c tive fro m a n ES P ro le
When performing the medical diagnostic task, the ESP may function in triage capacity, de ned as ‘a process in which a group of patients is sorted according to their need for care’ whereby ‘the kind of illness or injury, the severity of the problem and the facilities govern the process’ (Mosby’s Medical Dictionary 2009). Such an approach is widely advo cated in the literature relating to shoulder disorders including Mitchell et al. (2005), a best practice guideline entitled ‘The diagnosis and management of soft tissue shoulder injuries and related disorders’ published by the New Zealand G uidelines G roup (2004) and in the UK, guidance for the assessment and management of shoulder conditions published by the NH S Clinical Knowledge Summaries (NH S CKS 2012) Figure 4.14 below summarizes this group of work. It is beyond the scope and not the intention of this chapter to provide a comprehensive discussion of all known pathological lesions relating to the shoulder complex, but rather to discuss the
considerations and principles relating to diagnosis of shoulder conditions as they apply to both the physi otherapist performing a traditional role and the ESP performing the medical diagnostic task.
The importance of s creening for red ags As discussed in the fourth edition of M aitland’s Peripheral M anipulation (H engeveld & Banks 2005, page 82): physiotherapists employ highly complex clinical reasoning processes in which various paradigms to practice and different forms of clinical reasoning are followed. In some instances it will be a form of biomedical reasoning, in which the physiotherapist considers pathobiological processes mainly to detect precautions and contraindications to treatment. (Hengeveld 2000)
Screen for red flags
Screen for conditions which require early medical attention
Screen for extrinsic sources
Establish diagnosis of shoulder disorder
• Tumour? – Hx of cancer, symptoms and signs of cancer, unexplained deformity, mass or swelling; lymphadenopathy. Progressive, welllocalized pain, unrelated to movement, often night predominant, not reproduced by palpation or movement during examination • Infection? – Red skin, fever, systematically unwell • Neurological lesion? – Unexplained wasting, significant sensory or motor deficit • Pulmonary or vascular compromise?
• Acute rotator cuff tear? – Recent trauma, acute disabling pain and significant weakness, positive drop arm test • Unreduced dislocation? – Trauma, epileptic fit, electric shock, loss of rotation, abnormal shape • Young adult with acute traumatic primary anterior shoulder dislocation • Undiagnosed severe shoulder pain
• Cervical spine disorders • Thoracic spine disorders • Nerve disordersradiculopathy, brachial neuritis (also known as neuralgic amytrophy, Parsonage-Turner syndrome), thoracic outlet syndrome, Nerve entrapments inc. suprascapular, long thoracic nerve • Inflammatory disorderspolymyalgia rheumatica, rheumatoid arthritis • Visceral disordersheart, lungs, gallbladder, diaphragm, spleen, kidney • Complex regional pain syndrome
• Broad diagnostic titles include: • Rotator cuff disorders-rotator cuff tendinopathy, subacromial impingement, subacromial bursitis, rotator cuff tearspartial full thickness, massive, calcific tendonitis • Frozen shoulder • Ostoearthritisglenohumeral, acromioclavicular • Glenohumeral instability, labral lesions • Acromioclavicular lesions
Fig ure 4.14 • A diagnostic triage process that may be used in the medical diagnostic process relating to shoulder conditions. 16 9
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This aspect of physiotherapy practice has gained sig ni cant importance following the granting of autono mous status in the UK in 1977 under the terms of the H ealth Circular (77)33 (C SP 2008). Able to act as rst line clinicians, physiotherapists need not act as medical diagnosticians, but must be able to recog nize whether or not the signs and symptoms of a presenting complaint have their origin within the neuromusculoskeletal system, and if not, take appro priate action through directing the patient to the appropriate medical practitioner (H engeveld & Banks 2005, Maitland 1986, G rieve 1994). Red ags such as those identi ed by Mitchell et al. (2005), NH S CKS (2012) and the New Zealand G uidelines G roup (2004) provide an aid to the identi cation of possible serious pathology in shoulder conditions and are equally applicable to physicians and physiothera pists who undertake a traditional role and those with extended role and indicate the requirement for immediate referral to an appropriate specialist. Refer to Figure 4.14 for a list of red ags. ESPs who assume the responsibility for establish ing an appropriate medical diagnosis of musculoskeletal pathology require the development of a suf cient knowledge base of conditions, their possible differ ential diagnosis including the possibility of masquer ading serious pathology which in the early stages may not be evident as a ‘red ag’. The condition of frozen shoulder serves as one such an example. In a recent retrospective case analysis, Sano et al. (2010) reported that 32% of patients in a tumour service who were diagnosed with either primary or meta static tumors around the shoulder were initially diagnosed with frozen shoulder (n=9) or presented with symptoms characteristic of the condition (n=2) (3 males, 8 females, age range 51–77, mean 61 years). Secondly, in a review of 505 patients who presented to a shoulder service, 4 (0.8%) were diagnosed with malignant shoulder tumours (3 males, 1 female, age range 56–73, mean 67 years) (Sano et al. 2010). Interestingly, in six patients who were diagnosed with metastatic tumors, none presented with symp toms other than shoulder pain and restriction of range of movement and furthermore the tumors in this study were located inside the bone or in the scapular region in 73% of cases (Sano et al. 2010). Sano et al. (2010) consequently recommend that the possibility of musculoskeletal malignant tumour should always be considered in frozen shoulder, with the clinical diagnosis only being made in the presence of a normal X ray. This contention is supported by numerous authors including Codman (1934), Bunker 170
(2009) and Pearsall & Speer (1998), in addition to other authors who have reported other masquerading conditions including avascular necrosis (Wolfe & Taylor Butler 2000), melorheostosis (Jermin & Webb 2010) and osteoarthritis (Mitchell et al. 2005). Furthermore, Sano et al. (2010) suggest that if patients fail to respond in a manner consistent with the natural course of the condition, the diagnosis should be reconsidered and the patient should be re examined with repeated radiographs or further imaging studies, as in their study of nine patients with a tumour in which initial plain X rays failed to identify the pathol ogy. In contrast the New Zealand G uidelines G roup (2004) recommends the use of investigation only if arthritis is suspected. This example serves to high light some of the responsibilities and controversies that the ESP must contend with.
Screening for conditions which require early medical attention Although the physiotherapist will diagnose more frequently in terms of movement disorders than in structural diagnostics, attention needs to be given to acute symptoms due to posttraumatic situations, in which large structural lesions may have occurred and which may need the care of a medical practitioner. (Hengeveld & Banks 2005, p 152)
Again physiotherapists performing a traditional role need not act as medical diagnosticians, but must be suf ciently aware of shoulder conditions, where early medical attention is necessary and where delay in diagnosis of the structural lesion will be of detri ment to the patient. Some of the key conditions are highlighted in Figure 4.14. An example of such a condition relates to the patient with a previously asymptomatic shoulder, who sustains a direct injury to their shoulder, indica tive of a possible acute full thickness rotator cuff tear. Although thought to account for less than 10% of all rotator cuff tears, early surgical intervention in this group of patients is recommended and has been associated with superior outcomes (Bassett & Co eld 1983, Moosmayer et al. 2010, O h et al. 2006). As previously discussed, the orthopaedic special tests purported to identify this speci c shoul der lesion do not demonstrate likelihood ratios that would modify the post test probability of diagnosing a rotator cuff tear by a moderate or large amount, thereby questioning their utility (see Table 4.2 for
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description of statistical terms). At best, clinical evaluation, based on the results of one study by Park et al. (2005), has reported the likelihood of a rotator cuff tear to be more than 90% and a full thickness tear to be 28% in the patient who is more than 65 years of age, and presents with a positive drop arm sign combined with a weak ‘infraspinatus’ test. Nonetheless, as the only diagnostic tools available to the physiotherapist performing a traditional role, a clinical impression of a signi cant structural lesion can be established based on the history of the condi tion and the physical examination ndings which is suf cient to warrant referral to an appropriate medical practitioner or ESP performing the medical diagnostic task. Based on such a clinical impression the ESP would seek to arrange further investigation in the form of either diagnostic ultrasound or MRI to assess the integrity of the rotator cuff. Pooled sensitivity values of 0.95/ 0.89 and speci city values of 0.96/ 0.93 for the ability of diagnostic ultrasound and MRI respectively to detect full thickness rotator cuff tears have been reported (O ttenheijm et al. 2010, Shahabpour et al. 2008). These values allow con dent conclusions to be made to both rule in and rule out a full thickness rotator cuff tear (O ttenheijm et al. 2010, Shahabpour et al. 2008) and facilitate timely referral to a consultant ortho paedic surgeon should the patient be willing and medically t to undergo rotator cuff repair surgery. A second example relates to the young adult with acute traumatic primary anterior shoulder disloca tion. The risk of recurrent instability (redislocation or symptoms/ signs of shoulder instability) is high, up to 92–96% in the physically active, young indi vidual (Robinson et al. 2006, Wheeler et al. 1989). Although, there is no common protocol to guide the management of this condition, numerous authors consider that there is ample evidence to suggest that a speci c subgroup of younger athletes may bene t from early surgical stabilization, based on substantial reduction in redislocation rates and improved quality of life outcome measures (G ooding et al. 2010, Safran et al. 2007, Boone & Arciero 2010, H andoll et al. 2004). Findings from a longitudinal study with 25 year follow up undertaken by H olvelius et al. (2008), however, suggest that if immediate surgical stabilization were undertaken in all patients under 25, 30% of the surgery would have been unnecessary as this group of patients spontaneously stabilized over time. Unfortunately, however, at this stage there does not appear to be any evidence relating to a method of predicting who would require surgical
stabilization, although some authors have suggested young males (<25 years) involved in contact sports and overhead activity possess the greatest risk for future instability and redislocation (G ooding et al. 2010, Boone & Arciero 2010; H andoll et al. 2004). Numerous other considerations in the clinical decision making process of surgeons as to the suit ability of surgical stabilization have been reported, including the presence of the speci c underlying pathoanatomical lesion(s), particularly the identi cation of bony defects in addition to a bankart lesion (typically seen in 86–100% of young rst time ante rior shoulder dislocations) (G ooding et al. 2010, Boone & Arciero 2010). This group of patients requires, at minimum, a clear discussion of the surgi cal and conservative management options and risks with both approaches (G ooding et al. 2010, Boone & Arciero 2010). As Syme (2009) recognizes, ESP practice is guided in addition to the competencies detailed in Figure 4.1 by locally agreed protocols and referral pathways including recognition of the working practices and philosophy of the consultant teams. As such, the extent to which an ESP becomes involved in both the diagnostic work up and discus sions regarding the risks and bene ts of surgery will vary.
Screening for extrins ic s ources – analytical as s es s ment and differentiation Pain and problems experienced in the region of the shoulder have the possibility of being due to a myriad of extrinsically sourced pathology, with some of the key conditions illustrated in Figure 4.14 (Manifold & McCann 1999, Pateder et al. 2009, Mamula et al. 2005, Walsworth et al. 2004, H attrup & Co eld 2010). As discussed previously, it is not within the scope of practice of physiotherapists performing a tradi tional role to provide a medical diagnosis. Nonethe less, as with screening for red ags and clinical presentations which require early medical attention, physiotherapists need to possess an awareness of clinical ndings and presentations which suggest a possible extrinsic source of shoulder pain and dys function. Some such sources may fall within the scope of practice to be managed and treated within physiotherapy practice, such as movement impair ments in the cervical spine which cause or contribute 171
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to a patient’s functional limitations. O ther clinical presentations may suggest a possible underlying pathological condition which requires appropriate medical diagnosis and management and warrants contact with an appropriate medical practitioner. The clinical presentation of a winged scapula and scapula dyskinesis is one such example which may indicate a possible underlying neurological lesion as detailed in Table 4.5. Such screening is required by all physiotherapists performing a traditional role either when working as a rst contact practitioner or when assessing and managing patients referred by a physician or the extended role physiotherapist undertaking the diagnostic role. Tables 4.5, 4.6 and 4.7 seek to provide some of the key features of extrinsic conditions which may present as shoulder pain or dysfunction in physiotherapy practice.
Ce rvic a l s p ine d is ord e rs – a n e xa mp le of a n e xtrins ic s ourc e The continued clinical utility of the principles of the Maitland Concept to contemporary physiotherapy practice has been eloquently discussed in the previ ous edition of M aitland’s Peripheral M anipulation (H engeveld & Banks 2005) and developed in this chapter with respect to shoulder conditions. Many of the principles of the concept are equally applicable to the ESP, such as that discussed in this current chapter,
relating to the limitations and dif culties associated with diagnostic titles and labels which Maitland so clearly acknowledged. The use of ‘differentiation tests’ and ‘analytical assessment’ as described by Maitland (1986) are considered of particular importance to the Concept, and serve as further examples, pertinent to the current discussion relating to screening for extrinsic sources by the ESP. As an example of such a possible extrinsic source, Manifold and McCann (1999) consider cervical spine disorders as the most important and perhaps one of the most dif cult to differentially diagnose in patients with pain in the region of the shoulder and include conditions such as spondylosis, disc hernitation, radiculopathy and myelopathy. Fur thermore, Manifold and McCann (1999) consider that the cervical spine should be excluded as a pain source in all patients with shoulder problems and recognize the possibility of coexisting pathology with the consequential diagnostic and therapeutic chal lenge that such a patient presentation brings. Ration ale such as the anatomic proximity of the cervical spine and shoulder and similarity in both the clinical presentation and patient group demographics have been reported as some of the challenges to differen tial diagnosis (Manifold & McCann 1999, Pateder et al. 2009, H attrup & Co eld 2010). Maitland’s (1991) belief that a patient can have; 1. ‘More than one kind of pain”, 2. ‘Different pains in overlapping
Table 4.5 Peripheral nerve entrapments around the shoulder
Conditions
Some key eatures
Brac hial ne uritis Also known as neuralgic amytrophy, Parsonage–Turner syndrome (Parsonage & Turner 1948), brachial neuropathy, neuritis o the shoulder girdle, shoulder-girdle syndrome
A rare condition, incidence rates 1.64 cases per 100,000 reported, typically a ecting young adults, although a second peak o incidence in seventh decade also reported with male predominance 2 : 1–11.5 : 1 Unknown aetiology – has been associated with various actors proposed to cause the neuritis including trauma, in ection, virus, heavy exercise, surgery, autoimmune conditions, vaccinations. Most common cause o brachial plexopathy Characteristically presents with three stages; 1. acute onset o severe pain in the shoulder which may re er both distally into the arm and proximally into the neck which may persist or days to weeks, 2. therea ter ollowed by resolution o pain and the onset o painless paresis, atrophy and sensory impairment o the shoulder girdle and/or upper limb due to involvement o the brachial plexus or its component nerves and f nally 3. ollowed by gradual recovery Presentation can vary greatly dependent upon the predominant site o the lesion, i.e. upper, lower or whole brachial plexus, or the uncommon involvement o a single peripheral nerve. Typically the upper trunk o the plexus is a ected with supraspinatus, in raspinatus serratus anterior and deltoid particularly vulnerable Management is conservative, prognosis is good with 75% ully recovered at two years Examples: Miller et al. (2000), Hussey et al. (2007), Gonzalez-Alegre et al. (2002), Sumner (2009), Mamula et al. (2005)
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Table 4.5 Peripheral nerve entrapments around the shoulder—cont’d
Conditions
Some key eatures
Tho rac ic o utle t s yndro me (TOS) Other terms include cervical rib syndrome, costoclavicular syndrome, hyperabduction syndrome, pectoralis minor syndrome, thoracic inlet syndrome
Extremely controversial subject and syndrome as to its existence, diagnosis and management Considered broadly as neurovascular compression in a region correctly termed the thoracic inlet (the intersection o the neck and thoracic cavity, consisting o the upper end o the sternum (the manubrium), the f rst thoracic vertebra, and the f rst ribs and their cartilages) Associated with cervical rib, f brous bands, clavicular ractures, f rst rib, enlarged scalene tubercles, posture to name but a ew Due to the controversies regarding the syndrome, incidence also a source o controversy Physical tests are unreliable True vascular TOS-subclavian artery and/or vein is damaged or thrombosed demonstrated by arteriogram or venogram True neurogenic TOS-brachial plexus lesion identif ed by nerve conduction study or electromyography (EMG) studies Non-specif c or disputed TOS-presence o symptoms but no corroborating abnormalities on arteriogram/venogram/NCS/EMG Highly variable set o symptoms possible with pain, paraesthesia, weakness in the upper extremity, o ten vague, ill def ned Vascular symptoms include (a)- arterial compromise: pallor, arm claudication, coldness; (b) venous: edema, venous engorgement, cyanosis – consider Paget-Schroetter syndrome – (e ort) thrombosis o axillary-subclavian vein, uncommon deep vein thrombosis related to excessive upper extremity activity (requires early and urgent medical attention or diagnosis), thrombolysis and anticoagulation Neurogenic symptoms dependent upon sites(s) o lesion and include sensory and/or motor pain, paraethesias, dysesthesia, weakness, loss o dexterity, clumsiness, heaviness. Typically involvement o the lower plexus (C8, T1) can also involve upper plexus (C5, C6, C7) Examples: Sucher (2009), Novak & Mackinnon (1996), Naidu & Kothari (2003), Watson et al. (2009), Oktar & Ergul (2007)
Supras c apular ne rve e ntrapme nt
Uncommon, ?0.4%–2% o su erers with shoulder pain Suprascapular nerve mixed motor and sensory, supplying supraspinatus and in raspinatus, sensory f bres to acromioclavicular and glenohumeral joint capsule, no cutaneous sensory innervation Neuropathy as result o compression or traction at the suprascapular notch or spinoglenoid region Causes include: space occupying lesions, direct trauma, virus, idiopathic, repetitive/ orce ul scapular movement Typically pain, weakness/atrophy o supraspinatus/in raspinatus Conf rmed with nerve conduction studies, imaging may provide evidence o source o compression, i.e. ganglion cysts, other space occupying lesions Compressive lesions typically managed with surgery Examples: Walsworth et al. (2004), Pratt (1986), Ganzhorn et al. (1981), Coro et al. (2005)
Lo ng tho rac ic ne rve e ntrapme nt
Long thoracic nerve, a purely motor nerve, arises rom branches o C5, C6 and C7, and innervates the serratus anterior Aetiology: non-traumatic including in ection, virus, in ammatory, toxins, prolonged shoulder depression ?mani estation o brachial neuritis, traumatic thought to account or 53% o cases (May & Otsuka 1992) with vulnerability or injury rom multiple sources Clinical presentation: severe burning, aching pain, ollowed by weakness o serratus anterior and medial scapula winging (accentuated during elevation with elbows extended), limitation o shoulder elevation Causes medial scapular winging Most recover serratus anterior unction with conservative treatment but may take two years or more Examples: Pratt (1986), Aldridge et al. (2001), Duralde (2000), Waiter & Flatow (1999)
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Table 4.5 Peripheral nerve entrapments around the shoulder—cont’d
Conditions
Some key eatures
Do rs al s c apular ne rve e ntrapme nt
Dorsal scapular nerve arises rom C5, passes through the middle scalene innervating the rhomboids, may also innervate levator scapulae, no cutaneous sensory innervation Susceptible to entrapment through the middle scalene Typically scapular pain, possibly re erring to the lateral shoulder, lateral scapular winging (best shown during return to neutral rom elevation) Examples: Akgun et al. (2008), Pratt (1986), Aldridge et al. (2001)
Spinal ac c e s s o ry ne rve e ntrapme nt
Otherwise known as cranial nerve XI, and is the sole innervator o trapezius Superf cial course in the posterior cervical triangle makes it susceptible to injury Injury will cause dys unction o trapezius, leading to a drooping shoulder, lateral winging scapula (best shown with shoulder abduction), weakness o elevation Iatrogenic injury to the nerve a ter a surgical procedure is one o the most common causes, other causes include penetrating injury, and idiopathic Conf rmed with nerve conduction studies and EMG Idiopathic cause, treatment is conservative with >80% patients recovering within six to 12 months. Traumatic cause, surgical exploration indicated Examples: Sergides et al. (2010), Waiter & Bigliani (1999), Duralde (2000)
Axillary ne rve e ntrapme nt
Arises rom C5, C6 , supplying teres minor and deltoid, with a cutaneous branch supplying skin superf cial to lateral aspect o deltoid Associated with anterior shoulder dislocation, direct trauma to shoulder, space occupying lesions, quadrilateral space syndrome Symptoms are usually vague, pain poorly localized around the anterolateral shoulder, with possible paraesthesia in a non-segmental pattern, weakness and atrophy o deltoid Conf rmed with NCS or EMG; imaging may provide source o compression and demonstrate other eatures o the injury Examples: Aldridge et al. (2001), Duralde (2000)
Table 4.6 Spinal conditions which may prove to be an extrinsic source o shoulder pain and dys unction
Conditions
Some key eatures
Ce rvic al radic ulo pathy
Incidence highest in ourth and f th decade – 2.1 cases per 1000 Nerve root compression due to encroachment rom osteophytic spurs rom the lateral aspect o the cervical disc, zygopophyseal joints, uncovertebral joints (hard disc) or acute disc herniation (so t disc) Nerve root per usion a ected through compression o radicular arteries within the dural root sleeves by osteophyte Can prove challenging to di erentiate rom a primary shoulder problem Pain is neuropathic – results rom irritation o the spinal nerves and is re erred along the distribution o the nerve and the related dermatome (area o skin supplied by a single spinal nerve) – and is characteristically sharp, burning, lancinating May also be presence o nociceptive re erred pain (see below in other cervical conditions) Classically paraesthesia reported in a specif c dermatomal distribution, myotomal motor weakness, dermatomal sensory loss Positive spurling tests, with limited cervical rotation, positive upper limb neural tissue pain provocation test (NTPPT) and relie o symptoms with cervical traction provides +LR 30.3 (Wainner et al. 2003) Examples: Slaven & Mathers (2010), Mani old & McCann (1999), Hattrup & Cof eld (2010)
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Table 4.6 Spinal conditions which may prove to be an extrinsic source o shoulder pain and dys unction—cont’d
Conditions
Some key eatures
Ce rvic al mye lo pathy
Cervical spondylotic myelopathy most common type o spinal cord dys unction in patients >55 years Has been recognized as a cause o painless upper limb weakness without lower limb symptoms (anterior syndrome) Typically loss o upper limb dexterity; non-specif c upper limb weakness associated with gait disturbances, shoulder, neck and arm pain may also be present Typically lower motor neuron lesion signs at the level o the cervical lesion and upper motor neuron signs below the level o the lesion Clinical diagnosis investigated typically with cervical MRI Cluster signs o 1. gait deviation, 2. positive Ho man’s test, 3. inverted supinator sign, 4. positive Babinski sign, 5. age >45 years. 3 o 5 positive associated with +LR 30.9 (rules in presence o myelopathy), only 1 o 5 positive associated with −LR 0.18 (rules out presence o myelopathy) (Cook et al. 2010) Examples: Bernhardt et al. (1993), Cook et al. (2010)
Ce rvic o brac hial pain s yndro me – a clinical syndrome (a ter Elvey & Hall 1997)
Described as ‘upper quarter pain in which neural tissue sensitivity to mechanical stimuli is a primary eature’ (Elvey & Hall 1997) – a clinically based diagnostic label Absence o neurological def cit Presence o eatures suggestive o neural tissue involvement ‘i) active movement dys unction, ii) passive movement dys unction, iii) adverse responses to neural tissue provocation tests, iv) hyperalgesic responses to nerve trunk palpation, v) hyperalgesic responses to palpation o related cutaneous tissues and vi) evidence o a related local area o pathology’ (Elvey & Hall 1997)
Othe r c e rvic al c o nditio ns - spondylosis, disc herniation, acet OA, zygapophyseal sprain, myo ascial and postural pain syndromes
Somatic re erred pain or /nociceptive re erred pain Pain sourced rom tissues in the cervical spine other than neural tissue, i.e. ligament, muscle, zygapophyseal joint, intervertebral disc but perceived elsewhere Pain is re erred segmentally in a sclerotomal pattern (structures in the body wall and limbs which are innervated by a single spinal segment), which are di erent and more di use in their arrangement than dermatomes Sclerotomal distributions vary widely by individual – shoulder symptoms typically sourced rom C5 but also can be produced by stimulation o levels C1 to C8 Examples: Seaman and Cleveland (1999), Bogduk (1988)
Tho rac ic c o nditio ns
Conditions include: thoracic outlet syndrome (previously detailed), postural syndrome, T4 syndrome, f rst/second rib elevation, thoracic spondylosis, Scheuermann’s disease, Tietze’s Syndrome, ankylosing spondylitis Note: Maitland et al. (2005): ‘1. the upper/mid-thoracic spine, the ribs and their attachments can in uence the scapulothoracic and shoulder regions. This can be done by directly re erring the symptoms or by in uencing the dynamic postural stabilization and relative mobility o the shoulder and shoulder girdle …’ ‘2. The sympathetic chains are in close proximity to the costovertebral joints. Evans (1997) has suggested that arthritic costovertebral joints can cause mechanical irritation o the sympathetic chains. Subtle autonomic symptoms, especially in the limbs, may well be a consequence o such mechanical irritation’
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Table 4.7 Other examples o possible extrinsic sources o shoulder pain and dys unction
Conditions
Some key eatures
Vis c e ral dis o rde rs
Re erred visceral pain – pain which is stimulated rom within the visceral structures but experienced elsewhere; re erred nociceptive pain to the same segmental level as the visceral a erent neurons (convergence-projection theory (Ruch 1946, Robertson 1999) As discussed in the ourth edition o Maitland’s Peripheral Manipulation (Hengeveld & Banks 2005), the textbook Differential Diagnosis in Physical Therapy (Goodman & Snyder 1995) provides a use ul re erence resource to help physiotherapists recognize systemic disease which may mimic musculoskeletal dys unction Examples o visceral structures and systems which are capable o re erring pain to the shoulder include: cardiovascular, i.e. cardiac disease re erring to the le t shoulder, similarly the diaphragm (Walsh & Sadowski 2001); pulmonary, i.e. Pancoast tumour or pleurisy; the liver or gallbladder is capable o re erring pain to the right shoulder, scapula, chest wall; pancreas, or scapula region (Goodman & Snyder 2000)
Po lymyalg ia rhe umatic a
Characterized by ache, and morning sti ness (30 minutes or more) a ecting the shoulders (70–95% o cases), pelvic girdle and cervical spine (50–70% o cases) and appears due to proximal joint synovitis, a ecting those aged >50 years Closely related with giant cell arteritis Pain ul restriction o both active and passive shoulder movement without detectable joint swelling, ESR (erythrocyte sedimentation rate – a blood test indicative o in ammation) o >40 mmHg; however, has been reported normal in 7–20% cases Rapid response to glucocorticosteroids with near complete resolution o symptoms in a ew days Salvarani et al. (2008)
areas”, 3. ‘Different pains with different behaviours’, combined with the logical and methodical process of assessing cause and effect which are demands of the Concept, are important principles for the ESP undertaking the diagnostic task to consider in under standing the contribution of multiple symptom sources to a patient’s presentation, thereby establish ing as speci c a diagnosis as possible on which to base management decisions. Maitland (1986, 1991) further identi ed varying kinds of differentiation procedures, including those which attempt to ‘deter mine whether a pain disorder is arising from the spine or a peripheral joint’ and those which seek ‘to determine whether a pain is arising from the spinal joints or the pain sensitive structures in the vertebral canal or intervertebral foramen’. As an example, Maitland described a process of differentiation for the patient who reports ‘symptoms in the deltoid area which require differentiation procedures to determine whether they are caused by a cervical spine disorder or a glenohumeral disorder’. The original text is reproduced below: It is not uncommon for a person to seek relief of pain in the area suggested above. The patient may never have had neck or shoulder symptoms before. O n 176
examination of the physiological movements, the shoulder may be painful at the end of range(s); and the cervical spine’s physiological movements may be symptom free. Two other examination movements of the cervical spine must be tested before it can be said that the cervical spine is NO T affected: Compression of the cervical spine should be assessed by the therapist gradually increasing compression through the crown of the patient’s head endeavoring to compress structures on each side alternately, positioning the patient’s head and cervical spine in some extension, together with lateral exion and rotation towards the side of the pain. If the cervical spine is implicated, performing the procedure towards the side of the pain will probably be more uncomfortable than when performed on the side opposite to the site of the pain (Fig. 4.15). The second test is the primary test. This uses careful palpation of the appropriate vertebrae. The inter vertebral spaces are assessed to determine whether there is any abnormal position or thickening of related intervertebral levels. If there is a difference, such as thickened intervertebral tissue or prominence of relevant zygapophyseal joints, pain will probably be felt deeply when oscillatory unilateral pressure is applied in a postero anterior direction through the zygopophyseal joint. This is classed as an abnormal nding. Con rmation of no cervical structure contributing to the patient’s deltoid area symptoms will be evident if the
S h o u ld e r c o n d itio n s – a p e rs p e c tive fro m a n ES P ro le cervical spine is treated at two consecutive sessions without producing any change in the symptoms. Conversely, successful treatment of the spine with palpatory techniques will produce favourable changes in: The test movements of the shoulder The symptoms felt by the patient The palpation signs of the cervical spine. Maitland 1991 p 37–8
Fig ure 4.15 • Cervical compression test. With the patient sitting and the examiner standing behind the patient, the therapist cradles the top o the patient’s head in their hands and takes the neck into slight extension, rotation and ipsilateral side exion. A compression orce is then applied axially down through the head. Positive test = symptom reproduction in the arm.
Maitland (1991 p 38) further recognized the importance of differentiating ‘the cause of shoulder (and arm) symptoms being from a shoulder disorder, a neurogenic or dural disorder’ and acknowledged the pioneering work of Elvey (1979) in the development of the ‘brachial plexus tension tests’ within the Concept, as the procedure to facilitate this differen tiation. Although later re ned by authors such as Butler (1991, 2000) and H all & Elvey (1999), reinterpreted in light of contemporary developments in understanding relating to pain science and relabelled as neural tissue provocation tests (H all & Elvey 1999), the concept of structural differentiation in an attempt to clinically investigate the presence of neural tissue mechanosensitivity continues to inform contemporary clinical practice. Case study 4.2 describes an ESP assessment of a patient with persistent shoulder pain.
Cas e s tudy 4 2 An ESP assessment o a patient with persistent shoulder pain His tory Mrs R, a 67-year-old lady pres ented to an orthopaedic Clinical As s es s ment and Treatment Service (CATS) with a s ix-month his tory of ins idious ons et right s houlder pain She des cribed pain localized over the lateral as pect of the s houlder, intermittently radiating down the lateral as pect of the upper arm to the elbow (Fig 4 16) The pain wors ened when s he lifted her arm above s houlder height and when trying to place her hand behind her back She had dif culty was hing and drying her hair Her s leep was dis turbed mos t nights due to the s houlder pain, which s he felt was due to rolling onto the affected s ide Since the ons et of the s houlder pain s he reported noticing that her s houlder had been clicking and that her arm felt heavy Mrs R had initially undergone a brief cours e of phys iotherapy at her GP practice arranged by her GP She des cribed a home exercis e programme of various movements to the s houlder with the us e of a theraband including res is tive elevation and lateral rotation exercis es Unfortunately, this only s erved to aggravate her s ymptoms Due to a
failure to improve s he attended her GP who cons equently arranged an orthopaedic CATS referral The GP referred Mrs R with a diagnos is of ‘s ubacromial impingement s yndrome right s houlder’
Exa mina tion The key features identi ed during the phys ical examination were painful res trictions of the right s houlder to active elevation and abduction at 160° Lateral rotation was painfully res tricted at 60° (in comparis on to her left s houlder at 70°) Hand behind back was painfully res tricted to the level of her pos terior s uperior iliac s pine in the affected right arm with the left able to reach to the mid-thoracic region Us ing the res tricted elevation of her s houlder as her functional demons tration, a noticeable change to her s houlder range of movement and pain was produced when repeating the movement in various different cervical s pine pos itions Special orthopaedic impingement tes ts including Hawkins –Kennedy and empty can tes ts were pos itive
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Cas e s tudy 4 2—cont’d Fig ure 4.16 • Body chart o Mrs R. 1 Ache, constant, deep
1
2 Ache, intermittent, deep
2
1 1
2
Initial active range of movement as s es s ment of the cervical s pine was unremarkable with well-maintained active range of movement However, on clos er examination at the extreme of right rotation, right s ide exion and extens ion local neck pain was produced Des pite various combinations of cervical active range of movement, reproduction of comparable s houlder pain was not achieved Palpation of the cervical s pine revealed marked localized tendernes s in the region of the right C4, C5 and C6 facet joints Unilateral pos teroanterior mobilization of thes e levels was limited at half range by locally produced pain Unilateral anteropos terior mobilization of the s ame levels was limited at quarter range by locally produced neck pain but als o with provocation of comparable lateral s houlder pain A pas s ive mobilization technique in a unilateral pos teroanterior direction on the affected levels was applied in an attempt to analyze the affect that the impairments identi ed in the cervical s pine had on the s houlder s ymptoms and s igns During the pas s ive mobilization technique, the range of movement produced during the technique gradually increas ed in line with a reported eas ing of the locally produced dis comfort Following application of the technique, reas s es s ment of active s houlder range of movement revealed res toration of full range with dis comfort at the limit of both elevation and abduction Mrs R reported feeling that her s houlder movement was s ubs tantially eas ier and ‘lighter’ The dis comfort that had been pres ent at the limit of cervical right rotation, right s ide exion and extens ion had eas ed Interes tingly, the clicking s ens ation that Mrs R had reported had als o eas ed Mrs R reported being happy to try a further cours e of phys iotherapy (aimed at addres s ing the previous ly unaddres s ed impairments in the cervical s pine) having had a demons trable improvement within the
178
as s es s ment s es s ion She reported ‘relief’ that s he was able to lift her arm with les s pain and that her s houlder felt the mos t comfortable it had for s ix months
Tre a tme nt Mrs R underwent a further cours e of phys iotherapy as recommended Treatment cons is ted of pos teroanterior and anteropos terior mobilization of the cervical s pine (Fig 4 17) with progres s ing grade of technique in line with the s ymptoms and s ign res pons e and a change of glenohumeral s tarting pos ition from neutral to end-ofrange elevation Within three s es s ions the impairments in the cervical s pine had cleared with full pain-free range of active movement achievable both on s ingle plane and combined movements The previous ly impaired range of movement to pos teroanterior mobilization als o res olved In line with the
Fig ure 4.17 • Cervical anteroposterior accessory mobilization in cervical neutral in right shoulder elevation.
S h o u ld e r c o n d itio n s – a p e rs p e c tive fro m a n ES P ro le
Cas e s tudy 4 2—cont’d improvements made in the cervical s pine, the right s houlder res tored full range to active elevation and abduction with overpres s ure The hand behind back movement improved to the mid-lumbar region, but then failed to make any further improvement Further as s es s ment of upper limb neural provocation tes t with a radial nerve bias (ULNPT 2b) revealed impairment to the range of movement in comparis on to the unaffected left s ide Range of movement was impaired by the ons et of right lateral upper arm pain (comparable to Mrs R’s reported pain location [2] which was reduced with s tructural differentiation of neural tis s ue (cons is tent reduction of lateral upper arm pain when moving the wris t from exion to a neutral pos ition in the ULNPT 2b pos ition) As other obvious impairments to neural interface s ites in the upper quadrant were not identi ed, a gentle neural tis s ue gliding technique was applied Reas s es s ment of the impaired hand-behind-back movement demons trated improvement in range Continued treatment addres s ing this impairment over three cons equent treatment s es s ions (increas ing dos age as s ymptoms and s igns allowed) led to res toration of hand behind back to the mid-thoracic region At this s tage Mrs R was happy with the outcome having made a full return to her previous ly limited functional tas ks She was placed on a review lis t Her s ymptoms remained res olved two months later and s he was able to s leep undis turbed and continued to be able to undertake her daily life without s houlder dis comfort
Comme nt This cas e s erves to demons trate the importance of performing an in-depth and thorough as s es s ment of the s pine in patients with s houlder dis orders As advocated by Maitland et al (2005) ‘involvement of the cervicothoracic s pine intervertebral motion s egments s hould be cons idered in all dis orders of the s houlder Actual or potential movement impairment in thes e regions of the s pine can contribute mechanically to the ranges of movement available in the s houlder, as well as phys iologically to pain perceived in the s houlder but referred from cervicothoracic s pine s tructures Dis order of the cervicothoracic s pine often res ults in movement res triction of the s houlder due to the pres ence of neurophys iological re ex arc Mechanical irritation of the cervical or thoracic s ympathetic ganglia may enhance s ens itivity of nerves , res ulting in further aching and heavines s in the s houlder and arm’ (Butler 2000) Interes tingly, McClatchie et al (2009) have als o recently demons trated s igni cant reductions in s houlder pain and painful arc following cervical s pine pas s ive mobilization in a randomized, blinded, placebocontrolled, cros s over trial of 21 patients Similarly to the patient in this cas e s tudy, the s ubjects in the s tudy by McClatchie et al had an abs ence of neck pain, no
limitation to cervical movements and had previous ly been unres pons ive to previous phys iotherapy s es s ions ‘addres s ing s houlder pain through “traditional” methods of movement patterns , s trengthening and modalities s uch as ultras ound and cryotherapy’ McClatchie et al (2009) s ummarize that their ndings ‘lends credence to the argument that the cervical s pine might s till be involved in s houlder pain in the abs ence of any objective cervical limitations or s ymptom reproduction’ Further s upport to this contention is provided by Haddick (2007) who demons trated s igni cant improvements in SPADI s core (s houlder pain and dis ability index) – an outcome meas ure with both pain and dis ability domains which has been demons trated to pos s es s s atis factory validity, reliability and res pons ivenes s for clinical us e) from 83% to 1 5% over a ve-week cours e of phys iotherapy Treatment addres s ed identi ed impairments to cervical s pine acces s ory motion and mechanos ens itivity of neural tis s ue that were clinically reas oned and thought to be contributory to the patient’s s ymptoms of s houlder pain and pain-res tricted limitations to s houlder movement Interes tingly again in this cas e, the impairments identi ed on acces s ory motion tes ting in the cervical s pine (s tiffnes s ) did not directly reproduce the patient’s s houlder pain This lends further s upport to the need to s earch for all identi able impairments , particularly with s pinal acces s ory motion tes ting, to as s es s their effect on a patient’s s houlder s igns and s ymptoms Moreover, the cas e als o demons trates the us efulnes s of s everal of the principles of the Maitland Concept (s ome of which are lis ted below) to ESPs in mus culos keletal practice who perform a triage role s uch as undertaken in an orthopaedic CATS The quotes are taken from the previous editions of Maitland’s Vertebral Manipulation and Maitland’s Peripheral Manipulation and appeared in s ections detailing the principles inherent in the Maitland Concept: • •
•
• •
•
‘knowing the principles of differentiation tes ts and the methods of performing them’; ‘making us e of the patient’s functional movements , with which he/s he can demons trate his /her dis ability or dis order’; ‘the aim of examining movements to nd one or more comparable “s igns ” of an appropriate s tructure or s tructures ’; ‘the depth and detail of palpation examination of s oft tis s ues and acces s ory movements ’; ‘clinical proof of whether treatment is working or not is achieved by continually comparing the effects of the s elected treatment forms on the patient’s s igns and s ymptoms ’; ‘ awles s analytical as s es s ment’ – the keys tone to the concept – and ‘validation-proving each s tep in the clinical s ituation’
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Es tablis hing the medical diagnos is of the s houlder dis order A d ia gnos tic d ile mma Many of the pertinent issues including the contro versies, limitations and dif culties relating to the medical diagnosis of shoulder conditions have been discussed in the preceding sections and as such require evaluation and integration into practice by the ESP undertaking the diagnostic task (see Figure 4.14). The medical diagnosis and management of conditions affecting the shoulder complex has been reported to be ‘one of the most challenging areas of musculoskeletal medicine’ (Robb et al. 2009a) because:
• Individual common shoulder pathologies vary • •
•
•
•
widely in their clinical presentations It is common for various shoulder pathologies to coexist concurrently A high prevalence of structural pathology identi ed on imaging modalities has been identi ed in the asymptomatic population which means there is a signi cant chance of misrepresentation of a patient’s problem should imaging modalities not be used judiciously Physical tests developed which aim to differentially diagnose pathologies of the shoulder, in general, at this stage, have been shown to have a poor ability to do so Studies have demonstrated, in the vast majority of cases, unsatisfactory reproducibility of a number of proposed shoulder classi cation systems There appears to be a lack of consensus on the diagnostic criteria which constitute a speci c subclassi cation/ diagnostic label.
Cons id e ra tions re la ting to me d ic a l s hould e r d ia gnos is in p rima ry c a re Studies have demonstrated that the vast majority of shoulder disorders are managed in the primary care setting. In the United Kingdom, Linsell et al. (2006) reported a prevalence rate of 2.36% of people who consulted their G P with regard to a shoulder problem in the year 2000 in their sample (15,534/ 658,469 patients). O f these patients 9215 incident cases were followed up over a three year period. At the end of this three year period 2061 (22.4%) cases had been referred onwards from the 18 0
G P for further care. O f these only 6% of cases (n=554) were referred to an orthopaedic or rheuma tology clinic. 1316 cases were managed by physio therapists (14.2%). Similarly, van der Windt et al. (1996) reported a G P referral rate of only 10% to a shoulder specialist (consultant surgeon) in a Dutch study. In recognition of the diagnostic challenges posed by the shoulder complex, simpli ed evidence based classi cation systems have been proposed. Mitchell et al. (2005) contend that ‘an overcomplicated approach to diagnosis is unlikely to alter early con servative management in primary care’ and advo cated that ‘diagnosis should be pragmatic and based on clinical assessment’. This system is advocated and used in the UK by the O xford Shoulder and Elbow clinic within primary care (O akes 2009). In summary, Mitchell et al. (2005) recommended that patients are grouped into broad categories and pro vided with conservative treatment recommenda tions for each category based on best available evidence at that stage, essentially medication, steroid injections and physiotherapy. The broad classi ca tion groups were: • Red ags (discussed on page 169) • Rotator cuff disorders or impingement (ages 35–75) • G lenohumeral disorders (adhesive capsulitis ages 40–65; osteoarthritis >60) • Acromioclavicular disease (teenage to 50) • G lenohumeral instability. Unfortunately, at this stage, to the author’s knowl edge, there appears to be an absence of research studies examining the reliability and reproducibility of this classi cation system. It does, however, meet many of the recommendations made of proposed classi cation systems, most speci cally with regard to its attempted simplicity. It is also interesting to note the use of broad generic clinical diagnostic titles, recognizing the limited ability to establish a more speci c biomedical diagnosis based on the use of clinical examination alone re ective of the current evidence. Further research needs to be undertaken to examine whether such a classi cation system pos sesses more acceptable levels of reproducibility than those others previously discussed in the section ‘Diagnostic labels and shoulder conditions’. Recently an audit of the concordance of biomedical diagnosis between extended scope practitioners and ortho paedic consultants in a specialist shoulder clinic in the UK using similar broad diagnostic groups has
S h o u ld e r c o n d itio n s – a p e rs p e c tive fro m a n ES P ro le
been published (O akes 2009). Results demonstrated a fully comparable diagnosis in 65% of cases and partially comparable diagnosis in 31% of cases (most of the variance appeared to be from those patients with a mixed clinical picture who received more than one diagnostic label). Audits such as these demonstrate that ESPs possess the ability to catego rize patients with a similar ability to orthopaedic consultant surgeons. As discussed, ESPs work across a wide variety of settings, including those who work in primary or secondary care interface services and as part of their extended role assume the responsibility for estab lishing a medical diagnosis on which treatment deci sions are made. Patients typically are referred to interface services such as these at various stages in the duration of their musculoskeletal problems with varying levels of previous management. As Mitchell et al. (2005) discuss, for those patients with a recent onset of shoulder problems, once screened for red ags (see page 169) and indi cations of serious structural problems which would require early specialist medical consultation (see page 170), investigations such as ultrasound and magnetic resonance imaging to increase the speci city of the medical diagnosis are rarely indicated. Mitchell et al. (2005) contend that, at this stage, patient management in a broad range of shoulder conditions is conservative and that surgical interven tion is seldom required. Furthermore, the early use of imaging modalities may:
• Paradoxically increase the referral rates to orthopaedic surgeons given the high prevalence of structural pathology even in the asymptomatic population (Mitchell et al. 2005) • Increase the chance for misrepresentation regarding the source of a patient’s functional problems • Prove detrimental to conservative management – for example the identi cation of a partial rotator cuff tear, which is commonly initially managed conservatively, may in the patient’s mind focus their attention on the necessity for a surgical repair. The diagnostic labels and classi cation approach proposed by Mitchell et al. (2005) is one example which could be utilized by the ESP in this role at this early stage in a patient’s management, on which to base treatment decisions and communicate both with medical colleagues and physiotherapy colleagues.
In contrast to this approach in a recent editorial, Cook (2010) highlights the dominance and increas ing reliance on imaging and orthopaedic special tests to inform decision making which has developed in musculoskeletal practice over the past several decades. Factors such as time constraints, technol ogy improvements, recognition of the poor capacity of clinical testing to capture speci c conditions, liti gation potential, the ‘intolerance for uncertainty’ and the ‘pursuit of certainty in diagnosis’ are cited amongst some of the reasons for this developing trend (Cook 2010). The potential problems and limitations of the approach to assessment which is associated with a dependence upon imaging and special orthopaedic tests have been discussed in this chapter and section. The utility of the Maitland Concept, the demands of which include ‘a positive personal commitment to understand what the person (patient) is enduring’ and a mode of thinking which encourages the ‘primacy of clinical evidence’ to the ESP, (undertaking the diagnostic task on which decisions regarding prognosis and manage ment are made) is extremely valuable.
Cons id e ra tions re la ting to p a tie nts with p e rs is te nt s ymp toms As discussed, ESPs may assess and manage patients at many different stages in the duration of their musculoskeletal conditions. For those ESPs working in primary or secondary care interface services or specialist secondary care centres, a common presen tation is the patient with a shoulder complaint which has proven, at that stage, resistant to initial conservative treatment measures which may have consisted of medication, activity modi cation, steroid injections and physiotherapy (Burbank et al. 2008ab). Persistence of symptoms in shoulder conditions is not an uncommon nding. As previously dis cussed, current understanding of the pathoaetiology and pathophysiology of shoulder conditions is limited. Studies have indicated that only 50% of all new episodes of shoulder problems recover com pletely by six months with only a further 10% resolving completely at one year (Croft et al. 1996, van der Windt et al. 1996, Winters et al. 1999, Bot et al. 2005). Various studies have sought to identify factors that are associated with persistence of symp toms in shoulder conditions and include; long dura tion of symptoms at baseline (Reilingh et al. 2008, Kuijpers et al. 2006), high level of pain severity at 18 1
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baseline (Reilingh et al. 2008, Kuijpers et al. 2006), musculoskeletal pain elsewhere (Keijsers et al. 2010, Feleus et al. 2008), a recurrent complaint (Keijsers et al. 2010), low social support (Keijsers et al. 2010), older age (Keijsers et al. 2010), high body mass index (Keijsers et al. 2010), unemployment (Keijsers et al. 2010) and a variety of psycho social factors (Keijsers et al. 2010, Relingh et al. 2008, Kuijpers et al. 2006, G eorge et al. 2008). Essentially at this stage in a patient’s management the ESP who is performing the diagnostic role on which future management decisions are based is faced with a number of questions:
• Are there identi able reasons to explain the •
• • •
persistence of the problem at this stage – physical and psychosocial? H as the conservative management undertaken thus far been appropriate and thorough based upon the clinical impression of the shoulder condition? Are there any indications for a further course of conservative treatment? Is the patient willing to consider the surgical option for their shoulder condition? Is the shoulder condition one which would be helped by surgery? The indications for surgery require a speci c diagnosis and structural information, which is gained from both the clinical history and examination combined with ndings from a variety of imaging modalities.
Psychosocial considerations Psychosocial factors have been associated with and thought to in uence pain perception and the devel opment of chronic musculoskeletal pain, particu larly spinal pain (Linton 2000). With speci c regard to shoulder conditions a variety of recent research studies point toward a similar association. For example, Badcock et al. (2002) and Kuijpers et al. (2006) have demonstrated associations between general psychological distress and shoulder pain. More speci cally associations between catastro phizing and pain levels have been reported (Reilingh et al. 2008, G eorge et al. 2008). Catastrophizing is considered an ineffective and maladaptive coping style in which the patient views the pain as overly destructive, possesses a pessimistic view of their prognosis and is associated with the psychological concepts of magni cation and rumination (a repeti tive and passive focus on the symptoms of distress, its causes and consequences) (G eorge et al. 2008, 18 2
Relingh et al. 2008). Catastrophizing forms part of the fear–avoidance psychological model which also consists of a) fear of pain, b) kinesiophobia (fear of movement) and c) anxiety. Reilingh et al. (2008) demonstrated that catastrophizing, next to intensity of pain at baseline, was the strongest predictor of change in pain intensity at six months in a sample of 587 patients who presented to their general practitioner in the Netherlands (high levels of catastrophizing led to only small reduc tions of pain at six months). G eorge et al. (2008) reported that only catastrophizing had a positive association with persistence of pain (>4/ 10 visual analogue scale) at three to ve months postopera tively in a sample of 58 patients who underwent shoulder surgery for rotator cuff tendinopathy (with or without a rotator cuff tear), adhesive capsulits or SLAP lesion. Such evidence supports the need for a biopsychosocial approach to the management of shoulder conditions and points towards the limitations of a purely biomedical approach to shoulder pain and dysfunction. Further work needs to be undertaken to establish such links in other populations, and whether developing and imple menting treatment aimed at addressing such belief systems is bene cial in improving outcomes for shoulder pain sufferers.
Conservative management considerations As physiotherapists, ESPs are aware of the model of practice on which the physiotherapy profession is based (as discussed in the section ‘Shoulder condi tions – a physiotherapy perspective’). ESPs are therefore able to provide a link between the medical profession and the physiotherapy profession, under standing the requirement for medical diagnosis, but also able to recognize the limitations associated with the broad diagnostic labels and the usefulness and applicability of an impairment based approach, just as advocated by Maitland (1986). In essence, such an approach seeks to address modi able physical and movement based impairments thought to con tribute to a patient’s functional limitation and dis abilities as opposed to treating hypothesized speci c tissue based pathology. Case Study 4.3 aims to demonstrate the limita tions of a physiotherapy approach to management which is based on a hypothesized medical diagnosis by a physiotherapist. In both cases, following a failure to respond to initial physiotherapy, patients were referred by their G P to a musculoskeletal interface service such as CATS. Assessments were
S h o u ld e r c o n d itio n s – a p e rs p e c tive fro m a n ES P ro le
Cas e s tudy 4 3 Demonstration o impairment-based treatment His tory A 41-year-old gentleman was referred to phys iotherapy by his GP with the diagnos is of a ‘left-s ided rotator cuff problem’ Mr H was a t and healthy reman with no medical his tory and no current drug his tory He began with left-s ided s houlder pain two months prior to being as s es s ed by a phys iotherapis t The pain began ins idious ly, in the abs ence of any trauma, and was des cribed as an intermittent deep dull ache on the anterior as pect of the left s houlder joint area (Fig 4 18) The s ymptoms were only aggravated by overhead lifting, for example, when carrying ladders above his head The pain was immediate with the overhead movement but als o eas ed quickly after returning his arms to his s ide All other activities were unaffected and he continued to exercis e in a gym but had to avoid overhead lifts
Exa mina tion On phys ical examination he was noted to have mild atrophy in the s upras pinous fos s a and minor winging of the s capula Cervical movements were full and as ymptomatic Forward elevation and abduction of the left s houlder were painful from 90° to the end of range No further differentiation was performed Res is ted internal rotation was found to be s ymptomatic Special orthopaedic tes ts were then performed and the empty can tes t was deemed to be pos itive On palpation Mr H was tender over the anterior as pect of the glenohumeral joint and in the biceps groove
Tre a tme nt A hypothes is of s upras pinatus tendinopathy/a tear(? ) was made by the phys iotherapis t Mr H was then taught an exercis e programme of eccentric loading exercis e in exion and abduction from end of range to 90°, us ing a theraband On his return a week later the patient
reported no change and friction mas s age of the s upras pinatus tendon was commenced He was then taught s elf-friction mas s age Again he returned a week later with no change to his problem, at which point the phys iotherapis t s tarted to ques tion his compliance with the exercis es and s elf-treatment Friction mas s age to s upras pinatus was performed again and he was taught s capula-s etting exercis es Mr H was reviewed again four weeks later and s till had not improved His phys iotherapis t queried a rotator cuff tear and whether phys iotherapy was appropriate As a res ult, Mr H was dis charged back to his GP with a recommendation for him to be referred onto orthopaedics for an opinion as to whether any further interventions would be neces s ary
Outc ome A month later he was examined by an ESP in primary care, who found joint s igns with unilateral pos teroanterior acces s ory movements in the midcervical s pine on the left In addition the s houlder quadrant was examined and was found to be s ymptomatic at the peak Further phys iotherapy was reques ted with advice to addres s the s igns found Over the next two months Mr H was treated eight times with mobilization techniques applied to the cervical s pine and to the s houlder quadrant He was then dis charged fully functional
Ana lys is This cas e s tudy s erves to demons trate a s ituation where treating a s peci c biomedical diagnos is made following phys iotherapy as s es s ment was detrimental to the patient’s recovery The phys ical examination by the phys iotherapis t in this cas e appeared to be bias ed towards making a s tructural and pathology-bas ed diagnos is us ing s pecial orthopaedic tes ts to generate the hypothes es This
Fig ure 4.18 • Body chart o Mr H.
1 Intermittent dull ache, deep
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Cas e s tudy 4 3—cont’d medical diagnos is then formed the bas is on which treatment was directed There appear to be s everal clinical reas oning errors demons trated in the initial phys iotherapy management of this cas e worthy of note:
above-head activities When examined by the ESP, us ing a functional impairment-bas ed approach his s ymptoms were reproduced in the s houlder quadrant pos ition The ESP als o found joint s igns in the cervical s pine, which were then mobilized with further treatment s es s ions It is pos s ible that thes e s igns were the caus e of the s ource or a barrier to recovery for the s houlder dys function What is clear, however, is that when he was referred back to phys iotherapy for an impairment-bas ed approach his problem improved and he returned to function
1 As dis cus s ed in the s ections on differential medical diagnos is , s pecial orthopaedic tes ts alone do not provide s uf cient diagnos tic accuracy to allow a medical diagnos is of rotator cuff tendinopathy The treatment approach directed towards addres s ing this tis s ue-bas ed diagnos is is therefore awed 2 Phys iotherapy diagnos is as determined by the WCPT (2007) (s ee page 145) was not undertaken; this , therefore, limited recognition of the functional limitations of the patient and limited the s earch for as s ociated phys ical impairments 3 Initial treatment involved the us e of eccentric exercis e which has s hown promis e in the management of other tendinopathies , including Achilles , patellar and common forearm extens ors (Woodely et al 2007) Unfortunately, there is limited evidence of s uch an approach in the management of rotator cuff tendinopathy In an uncontrolled pilot s tudy J ons s on et al (2006) reported ve of nine patients with a clinical diagnos is of impingement had a s atis factory outcome at 12 and 52 weeks following treatment 4 Although a phys ical impairment was identi ed (s capular dys kines ia), the effect with which this impairment contributed to the patient’s functional limitations was not as s es s ed within clinic (abs ence of analytical as s es s ment [Maitland 1986]) It is interes ting to note that following a further cours e of impairment-bas ed treatment in phys iotherapy the patient achieved a s atis factory outcome without the need to addres s the s capula dys kines ia directly 5 During the patient’s third treatment s es s ion the phys iotherapis t began to ques tion the patient’s compliance with the home exercis e pres cribed Unfortunately, in the authors ’ experience, this is not an uncommon occurrence It is worth noting at this point that, when cons idering communication, one of the fundamental principles of the Maitland Concept is to lis ten and believe the patient In this cas e it was perhaps more comfortable for the phys iotherapis t to think that the patient was not being compliant than to believe the pres cribed treatment was not being effective 6 At the point of phys iotherapy dis charge following the initial cours e of treatment, the phys iotherapis t was s till thinking and reas oning biomedically, in s us pecting a rotator cuff tear to be the reas on for the lack of improvement The patient clearly had a functional impairment, which was only apparent on
18 4
The s hould e r q ua d ra nt – a b rie f a p p ra is a l •
•
•
The quadrant is a functional movement of the s houlder des cribed by Maitland (in 1977 (and s ubs equent editions to 2005), and relevant to Mr H’s s ymptoms , and is that pos ition approximately 30° lateral to the fully exed s houlder pos ition where the arm has to move anteriorly and automatically rotate to achieve the fully exed pos ition It can be us ed in both examination and treatment for minor limitations of s houlder movement It is als o us eful as a s creening tes t to implicate or rule out the s houlder as a s ource of arm pain and to res tore the ideal functional s houlder range It can als o prove us eful as a reas s es s ment tool (Magarey & J ones 2005) The s houlder quadrant is not a diagnos tic tes t, but Mullen et al (1989) on examining four cadavers , identi ed the following s tructures as being compromis ed during examination of the quadrant: •
•
contact between the humerus and the s capula, compres s ion of the tendon of the long head of biceps at 120°–135°, the anteromedial part of the inferior s urface of the acromion in contact with the humerus , • the coracoacromial ligament is s tretched at 105°– 135°, • The greater tuberos ity (s upras pinatus ) is always impinged on the coracoacromial arch, • the coracoid proces s and the s ubs capularis area of the les s er tuberos ity impinges at 120°–135° of abduction When us ed as treatment technique to addres s movement impairment at the s houlder reas oned to be due to local s ymptom s ource, cons ideration is paid in particular to the s everity and irritability of the individual patient’s clinical pres entation Guidelines to help decis ion making regarding the amplitude and rhythm of the technique as it relates to different clinical pres entations are detailed els ewhere, for example, in Chapter 6 of Hengeveld and Banks (2005)
S h o u ld e r c o n d itio n s – a p e rs p e c tive fro m a n ES P ro le
Cas e s tudy 4 3—cont’d
Patient lying supine Anterior Peak Mound Elbow's path
Mound Cave
Superior A
Median frontal plane
Inferior Posterior
Fig ure 4.20 • Side-on view o the path o the right elbow as seen rom the patient’s right side looking horizontally towards the patient’s le t side. The path traverses a line into the ‘cave’ o the locking position, over the ‘mound’ o the quadrant passing the ‘peak’ o the quadrant.
Patient lying supine Anterior Median frontal plane B
Fig ure 4.19 • A Mobilizations on the low side o the shoulder quadrant. B Mobilizations on the high side o the shoulder quadrant.
Posterior
Fig ure 4.21 • Side-on view o the path o a patient’s elbow when movements are restricted and the ‘locking position’ lost.
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performed by ESPs who were consequently able to identify the presence of signi cant physical impair ments that were hypothesized to contribute to the functional limitations of the individuals and which had not been previously addressed in physiotherapy. Satisfactory outcomes and a return to previously limited activities were achieved in both cases follow ing a further course of physiotherapy directed to these speci c physical impairments using principles inherent to the Maitland Concept, including ‘ana lytical assessment’, and ‘clinical proof of whether treatment is working or not is achieved by continually comparing the effects of the selected treatment forms on the patient’s signs and symp toms’ (Maitland et al. 2005). These examples serve to provide further evidence of the bene ts of an impairment based approach in physiotherapy as advocated by Maitland (1986). Further case reports by H addick (2007) and Tate et al. (2010) lend further support to such an approach in the physiotherapy management of shoulder pain.
Surgical considerations As discussed by Chaudhury et al. (2010) only a small proportion of patients with shoulder pain will require surgery. This opinion is supported in the light of evidence from work undertaken by Linsell et al. (2006) who demonstrated that of 15,534 patients who consulted their G P with regard to shoulder problems during the year 2000, only 554 (3.6%)
were referred to either a orthopaedic or rheumatol ogy clinic over a three year follow up period. Unfor tunately, the design of the study did not report the conversion to surgery rates from these clinics. G enerally other than those conditions screened for with red ags (page 169) and those that require early medical attention (see page 170), the general indications for shoulder surgery include a failure to respond to conservative strategies over a three to six month period (Chaudhury et al. 2010). The indications for surgery are dependent upon a clear diagno sis and structural information, both of which are obtained from the patient’s history, physical exami nation and ndings from appropriate imaging modal ities (Chaudhury et al. 2010). At this stage, a speci c diagnosis (or as speci c as possible) is required in order to inform decision making regard ing a patient’s suitability for surgery. As previously discussed, ESPs may work in a variety of roles undertaking any number of a variety of tasks, traditionally undertaken by other profes sions (C SP 2008, Syme 2009). O ne such role undertaken by ESPs is the ability to refer patients to an orthopaedic consultant, or work on their behalf in identifying those patients who may bene t from the surgical option for their given shoulder condi tion. Case study 4.4 serves to demonstrate one example of a patient’s journey to shoulder surgery. It is beyond the scope and not the intention of this chapter to detail and discuss all the surgical consid erations relating to the shoulder; however, a brief
Cas e s tudy 4 4 ESP assessment o a patient with persistent shoulder pain and dys unction A 33-year-old gentleman was referred to an orthopaedic primary or s econdary care interface s ervice (CATS) by his GP and was as s es s ed by an ESP
His tory Mr A pres ented with an eight-month his tory of right s houlder pain and los s of function following an accident s us tained at work He worked as a car tyre and exhaus t tter in a garage and recalled pulling forcefully on a lever with his right arm in an attempt to replace a tight- tting tyre onto a wheel Mr A reported a s udden ons et of s evere anterior s houlder pain and a ‘tearing’ s ens ation deep within his right s houlder joint (Fig 4 22)
18 6
He reported ongoing problems with the s houlder from this time His problems at the initial as s es s ment were reported as : 1 a deep-s eated aching s ens ation within the anterior and lateral as pect of the s houlder; 2 an intermittent s ens ation of neck pain and s tiffnes s on the right s ide, which had been pres ent over the preceding one-month period; 3 dif culty and pain when attempting to elevate his arm above s houlder height; 4 pain and weaknes s when trying to lift, pull or pus h us ing the right arm Cons equently, he reported hims elf as ‘s truggling’ at work although he had not taken any abs ence On dis cus s ion it became evident that he felt s omething was wrong or loos e deep ins ide his s houlder
S h o u ld e r c o n d itio n s – a p e rs p e c tive fro m a n ES P ro le
Cas e s tudy 4 4—cont’d Fig ure 4.22 • Body chart o Mr A. 1 Ache, constant, deep
Mr A had undergone cons ervative management by the time of his initial as s es s ment in the interface clinic This had cons is ted of two s teroid injections provided by his GP, two and three months after the ons et of the problem and latterly a three-month cours e of phys iotherapy Mr A reported that neither injection had offered any relief of his pain The anatomical s ite of the injection was not able to be es tablis hed The cours e of phys iotherapy had als o failed to eas e his pain or improve his function A s houlder X-ray arranged by his GP was reported as normal His general health was good, and there were no other coexis tent mus culos keletal problems He had no his tory of previous s houlder problems
Exa mina tion Obs ervation revealed a s lightly depres s ed right s houlder girdle, rounded s houlders and a forward head pos ture Shoulder active elevation and abduction were painfully limited at approximately 160°, with increas ed pain through range from around 60° Pas s ively with care near full range of elevation and abduction was achievable with pain through range Through both active and pas s ive range Mr A incons is tently reported a clicking s ens ation from within his s houlder Lateral rotation range was well maintained and s imilar to the non-affected s ide Abnormal s capula motion on the affected s ide (s capula dys kines is ) was clearly evident through active range of movement of the s houlder mos t notably when returning the arm to the s ide from elevation and abduction with prominence of the medial border Strength tes ting of the rotator cuff revealed s trong contractions of both medial and lateral rotation, with mild pain produced on lateral rotation maximal contraction Glenohumeral acces s ory movements were painfully res tricted Glenohumeral and acromiohumeral joint compres s ion were pain provocative Cervical
2 Ache, stiffness, deep
s pine active range of movement was res tricted mos t notably in right rotation, and right s ide exion producing pain in the right mid- and lower cervical s pine region with mild pain produced towards the right s capula A neurological examination of the upper limbs was unremarkable Special orthopaedic tes ts were undertaken Pos itive res ults were as s ociated with a number of impingement and SLAP tes ts
Ana lys is The pain in the region of the s houlder that Mr A was experiencing was caus ing him s igni cant functional problems He expres s ed concern that he had ‘torn s omething’ at the time of the injury and was frus trated that he had made little progres s in (cons ervative) treatment thus far He was keen to have a medical diagnos is and was prepared to undergo s urgery s hould it be neces s ary to help his problem The clinical picture was mixed, with many phys ical impairments evident Cons idered within the differential medical diagnos es were: intra-articular glenohumeral dis order – SLAP, glenohumeral ins tability, acromiohumeral s ource – ‘impingement’ as a non-s peci c label with no evidence of a s igni cant rotator cuff tear, caps uloligamentous tear, biceps tendinopathy, long thoracic nerve les ion or brachial plexopathy, concurrent and s eparate mechanical neck pain The patient cons ented to further inves tigation by the ESP in an attempt to improve the s peci city of the diagnos is and upon which to bas e further management decis ions A nerve conduction s tudy was arranged to exclude a brachial plexopathy or long thoracic nerve les ion A MR arthrogram was arranged in cons ultation with an orthopaedic s houlder s urgeon to as s es s for a pos s ible SLAP les ion
18 7
C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
Cas e s tudy 4 4—cont’d Outc ome The res ults from the nerve conduction s tudy were normal and revealed no electrophys iological evidence for a brachial plexopathy or long thoracic nerve les ion The MR arthrogram reported ‘SLAP les ion with involvement of the anterior s uperior labrum No rotator cuff tear s een ACJ degeneration with inferior os teophytos is ’ Bas ed on the res ults of the his tory, phys ical examination, imaging, failure to res pond to cons ervative management and willingnes s to undergo s urgery, Mr A was referred via the primary or s econdary care interface s ervice to a s pecialis t orthopaedic cons ultant s houlder s urgeon At arthros copy a SLAP les ion was con rmed and arthros copic SLAP repair was cons equently performed without complication The patient underwent pos toperative rehabilitation in phys iotherapy addres s ing phys ical impairments within the boundaries of tis s ue healing Mr A made a return to full normal duties at work by week 16
Comme nt This cas e s tudy s erves as an example to demons trate a s ituation where a s peci c medical diagnos is was required on which to bas e further decis ions regarding a patient’s management, a role traditionally undertaken by the medical profes s ion, but now increas ingly being performed by extended s cope phys iotherapis ts It
summary of some of the more common procedures for the most common shoulder conditions is included in Tables 4.8–4.15.
Summa rie s of the mos t c ommon s hould e r d is ord e rs – a b iome d ic a l p e rs p e c tive with imp lic a tions for ESP a nd tra d itiona l p hys iothe ra p y p ra c tic e This section provides, in a table format (Tables 4.8– 4.15), summaries of the main pathological condi tions which affect the shoulder and shoulder girdle complex. Brief summaries of the current state of understanding of the pathology, aetiology, the typical presentations and associated medical management are included. In addition, and more speci cally, the tables include comments that are directed at physi otherapists performing a traditional physiotherapy role as to the implications to consider for each of 18 8
demons trates the mixed clinical picture often as s ociated with a SLAP les ion (detailed in Table 4 13 ) and the requirement to pos s es s a broad and deep knowledge bas e of pathology, differential diagnos es and the cons equent management required of ESPs in s uch a role (Syme 2009) Moreover, it als o s erves to demons trate the us efulnes s of a further fundamental component and principle of the Maitland Concept, that is the body’s inherent capability and capacity to in orm , part of the patient-centred approach to management that Maitland advocated. Maitland (1986) recognized that ‘the patient’s body can tell him things related to his dis order which we can never detect through objective examination’ Such a principle appears particularly relevant to this cas e, when acknowledging the current s tate of s cience indicating the lack of accuracy that clinical examination tes ts pos s es s in differentially diagnos ing pathologies at the s houlder The patient’s des criptions clearly indicated the pos s ibility of a s tructural les ion within the s houlder joint, which he felt would not be able to improve with time or cons ervative treatment Such a principle is an es s ential component of a clinician’s practice whether the phys iotherapis t is performing a traditional role or extended role, providing ‘vital information about his dis order, which is very important to as s es s ment, treatment and prognos is ’ (Maitland 1986)
the shoulder conditions. The section ‘Shoulder con ditions – a physiotherapy perspective’ further dis cusses how to integrate this knowledge into traditional physiotherapy practice. The tables are not exhaustive but cover some of the more common conditions that may encountered in clinic and include:
• • • • • • • •
Rotator cuff lesions Shoulder impingement Calcifying (calci c) tendinits Frozen shoulder G lenohumeral osteoarthritis G lenoid labrum SLAP lesions Shoulder instability Acromioclavicular lesions. Text continued on p. 213
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C H AP TE R 4 Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Sho ulde r c o nditio ns – a phys io the rapy pe rs pe c tive An overview As discussed in previous sections of this chapter, physiotherapy practice and the model of care on which the profession is based contrasts signi cantly with the biomedical model of healthcare. Whereas the biomedical model and framework of thinking is concerned with identifying pathology and diagnostic labels to specify a disease on which decisions are made regarding examination and treatment, physi otherapy practice is concerned with the identi ca tion of impairments which contribute to a patients functional limitations and possible disabilities with the aim of maximizing movement potential and quality of life. Readers are asked to revisit the second section of this chapter on diagnostic consid erations (page 144) and Figure 4.1, in particular, to review the World Confederation of Physical Therapy (WCPT 2007) position statement with regard to its description of the physiotherapy profession and stance on physiotherapy diagnosis. The limitations of an approach in physiotherapy management of shoulder conditions based solely on proposed tissue pathology identi ed using skills within the scope of physiotherapy practice, namely clinical examination, has been discussed in detail in previous sections in this chapter. Readers are asked to review Case study 4.3 in particular in this regard. Furthermore, the high prevalence of tissue pathol ogy in asymptomatic individuals particularly relating to rotator cuff disorders, considered to be the leading cause of shoulder pain and dysfunction and labral lesions, also highlights the potential aws should physiotherapy management only be based on the results of investigations arranged by a physician or ESP. In contrast, physiotherapy practice and patient management is based upon addressing modi able individual physical impairments which are clinically reasoned to be responsible and explain an individu al’s functional limitations. A recent study, using a Delphi approach of expert clinicians’ clinical rea soning strategies in assessing and managing shoulder pain, demonstrates the primacy given to movement impairments, based on history and signs and symp toms established during the clinical examination as opposed to speci c structural diagnoses using special
orthopaedic tests in 26 expert therapists supporting this stance (May et al. 2008). Impairments may be present as the direct result of a pathological process or conversely, as discussed in greater detail by Sahrmann (2002) and other authors, may actually lead to tissue pathology. In cases where physical impair ments are not modi able, physiotherapists work with patients in a collaborative process to establish strategies to compensate, thereby maximizing their quality of life, movement potential and functional ability.
Phys iotherapy diagnos is and s houlder conditions Relating to shoulder conditions, diagnostic titles such as subacromial bursitis, rotator cuff tear, bicipi tal tendonitis, supraspinatus tendinosis, calci c ten donitis, glenohumeral osteoarthritis, labral tear, suprascapular neuropathy are examples of medical diagnoses which imply pathoanatomical lesions as the cause of a patient’s disability. As discussed, clini cal examination alone, utilizing a variety of ortho paedic special tests, does not appear to possess satisfactory diagnostic accuracy, and thus supple mentary investigation such as X ray, diagnostic ultra sound, MRI, magnetic resonance arthroscopy are used to aid the speci c structural diagnosis to allow these diagnostic terms to be utilized. As diagnostic radiological investigation lies outside the scope of traditional physiotherapy practice, diagnostic labels such as these should not be established by physio therapists. The limitations, dif culties and implica tions of speci c medical diagnoses of shoulder conditions for physiotherapy practice have been pre viously discussed. Furthermore, the complexities associated with establishing a speci c structural diagnosis in the shoulder, brings with it the potential for misrepresentation of the source of a patient’s disability. This evidence appears to support the pre vious contentions of Maitland and other authors including Sahrmann (1988) that ‘the medical diag nosis is not a suf cient diagnosis to direct physical therapy’ (Sahrmann 1988). Physiotherapy diagnosis is considered by the WCPT as a professional responsibility of physiother apists and is described as: The result of a process of clinical reasoning which results in the identi cation of existing or potential impairments, functional limitations and abilities or disabilities … 2 13
C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
The purpose of the diagnosis is to guide physical therapists in determining the prognosis and most appropriate intervention strategies for patients or clients and in sharing information with them’ … This may be expressed in terms of movement dysfunction or may encompass categories of impairments, activity limitations, participatory restrictions, environmental in uences or abilities/ disabilities. WCPT (2007)
P hys iothe ra p y d ia gnos is a nd the ICF In 2003, the WCPT supported the implementation and integration of the International Classi cation of Functioning, Disability and H ealth (ICF) within the physiotherapy practice. The ICF was developed in 2001 by the World H ealth O rganization (WH O ) to provide both a conceptual framework and a basis for classifying and describing human functioning and disability. The ICF captures the interaction of body structure and function (impairments) with activities (limitations) and participation (restrictions) within the contextual factors of the person, the individual’s environment and health condition. The ICF offers a number of potential bene ts to physiotherapy prac tice. It:
• Provides a framework with which
•
• •
• •
physiotherapists are able to better understand the experience of the individual and how their health condition impacts on their functioning and disability. Facilitates the identi cation of impairments which could be addressed by a physiotherapist within their scope of practice and sets them within the context of activity limitations and participation restrictions experienced by the individual. Assists in determining appropriate goals, the prioritization of treatment selection and prognostic reasoning. Provides a common international language which facilitates communication surrounding many aspects of patient care and avoids many of the controversies and limitations associated with the pathoanatomical labels relating to shoulder conditions discussed in this section. Ful ls the role and requirement of a physiotherapy diagnosis as described by the WCPT. Provides a comprehensive classi cation system of functioning. 2 14
It is interesting to note how this contemporary stance ts with the central core or theme to the Maitland Concept namely ‘a positive personal commitment to understand what the person (patient) is enduring’ (Maitland 1986). ‘It is inclusive and places the patient and their main problems at the centre of everything the manipulative physiotherapist will do or say’ (H engeveld & Banks 2005). Furthermore, Maitland advocated ‘an open minded attitude to treatment techniques, being able to innovate freely, unhindered by theory; and to relate the techniques to functional disturbances’ (Maitland 1986). This thinking pro motes the individualization of treatment techniques to each patient as appropriate. O f further note at this point is that the early Maitland texts were never intended to be read as technique books. Rather the most important message lay in the underlying princi ples on which the techniques were based. It is easy to see principles such as ‘a patient driven model’, ‘using the body’s capacity to inform’ and emphasizing the ‘primacy of clinical evidence’ within the model of care based upon the ICF framework. The utility of the ICF in physiotherapy clinical practice has been demonstrated in a series of case reports by Rundell et al. (2009) and H elgeson and Smith (2008) relating to acute and chronic low back pain and patellar dislo cation respectively. Furthermore, ICF based practice guidelines have been published relating to neck pain (Childs et al. 2008), hip pain (Cibulka et al. 2009) and heel pain (McPoil et al. 2008) as a reference to guide and facilitate patient management in these groups. Upcoming guidelines relating to shoulder conditions are believed to be being developed at the present time (G odges & Irrgang 2008). The practicalities, challenges and opportunities of integrating and applying the ICF into physiotherapy practice have been discussed by Escorpizo et al. (2010) in a perspective article. Clearly, there is a requirement for future research to investigate the application of the ICF to other body regions and conditions. Although the ICF provides a powerful conceptual framework to underpin physiotherapy practice and a means of classifying and coding human functioning, it does not replace nor detract from other models of practice such as evidence based care or clinical reasoning models like those proposed by Edwards et al. (2004). Rundell et al. (2009) demonstrates how models such as these can be integrated with the ICF in clinical practice. A conceptual model by H engeveld (1999) demonstrates the integration of a manual therapy speci c taxonomy of movement impairment analysis with the ICF (Fig. 4.23).
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Participation – social roles
Individual illness experience (prioritizing treatment goals)
Activities – resources/restrictions Precautions Contraindications
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Muscle functions
Neurodynamic functions
functions
Treament goals
Movement impairments Pathobiological processes Stages of tissue healing
Others: blood vessels, viscera
Soft tissue functions: skin, fascia, connective tissue
Fig ure 4.23 • Model o ICF with the integration o a manual therapy specif c taxonomy o impairment analysis. Adapted rom Hengeveld 1999 , with permission.
Phys iotherapy diagnos is and s houlder conditions – the American Phys ical Therapy As s ociation pers pective The disparity between the biomedical model of diagnosing tissue based pathology and the physio therapy model of assessing and treating impairments which contribute to an individual’s functional limita tions, was recognized by the American Physical Therapy Association (APTA) in the publication of their document – G uide to Physical Therapist Prac tice (the G uide) (APTA 1998). ‘The G uide’ sought to classify patients in ‘preferred practice patterns’– diagnostic groups based on clusters of impairments as opposed to pathologies – in order to provide a framework for practice and on which clinical guide lines could be established that were within the scope of traditional physiotherapy practice. As such, patients with different pathologies and biomedical diagnoses may be classi ed within the same group. Conversely, patients with the same given biomedical diagnosis may be assigned to different groups. Tovin and G reen eld (2001) integrated this classi cation strategy, on which physiotherapy treatment is guided, to the principles of assessment and physio therapeutic treatment of the shoulder identifying the ‘preferred practice patterns’ as:
• Impaired joint mobility, motor function, muscle performance and range of motion associated with capsular restriction:
○ the primary impairment in this category is
limited shoulder movement, in a capsular pattern typically associated with either 1. structural changes in the shoulder in biomedical conditions such as frozen shoulder, arthritic conditions of the shoulder complex (i.e. osteoarthritis glenohumeral joint) or following immobilization post trauma, or 2. conditions with no associated structural changes in the shoulder complex where pain and protective muscle spasm restrict shoulder movement in a capsular pattern, for example, with acute in ammation within the shoulder complex or myofascial pain. • Impaired joint mobility, motor function, muscle performance and range of motion associated with ligament or connective tissue disorders (shoulder instability): ○ primary impairment in this category is instability with secondary impairments, that is, poor neuromuscular control associated with a variety of possible underlying tissue pathology such as capsular and ligamentous laxity through trauma or hypermobility syndromes, glenoid labrum pathology, rotator cuff injury and bony (joint) geometry. • Impaired joint mobility, motor function, muscle performance and range of motion associated with localized in ammation: ○ impairments of range of movement, motor function and muscle performance attributed to a protective tissue response due to 2 15
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in ammation and pain are encompassed within this category. Biomedical diagnoses associated with this category include acromioclavicular, sternoclavicular sprain, rotator cuff tears, pathology of the glenoid labrum, tendonitis, bursitis, capsulitis or frozen shoulder (early stage), tenosynovitis and impingement. • Referred pain syndromes: Impaired joint mobility, motor function, muscle performance and range of motion or re ex integrity secondary to re ex sympathetic dystrophy, spinal disorders, thoracic outlet syndrome and peripheral nerve entrapments: ○ impairments affecting tissues and structures in the upper quarter of the body which cause altered shoulder movement and/ or pain are included within this category, associated with conditions such as cervical / thoracic dysfunction, adverse neural tension, thoracic outlet syndrome, sympathetic pain, myofascial pain syndromes and postural problems. • Impaired joint mobility, motor function, muscle performance and range of motion associated with racture: ○ primary impairments are the associated loss of range of movement of the shoulder complex and reduced muscle performance secondary to disuse. • Impaired joint mobility, motor function, muscle performance and range of motion associated with joint arthroplasty or surgical procedures: ○ primary impairments include range of movement, motor function and muscle performance, the physiotherapeutic treatment of which must consider healing constraints. It is interesting to review this contemporary stance held by the APTA detailing an approach to physi otherapeutic treatment of shoulder conditions (and other conditions) which is based on impairments and functional limitations, in respect of Maitland and the development of the Maitland concept which advocated just such an approach. A comparison to the clinical pro les detailed in the fourth edition of M aitland’s Peripheral M anipulation (H engeveld & Banks 2005) produces many similarities to this classi cation system. It is also worth noting that this contemporary stance can still sit nicely along side Maitland’s clinical grouping system. Maitland advocated classifying patient’s symptoms and signs 2 16
into recognizable groups for the purposes of selec tion and progression of mobilization or manipulation techniques. Maitland recognized that the individual groups should respond to appropriate mobilization/ manipulation in a particular way, that is, group 1 – pain dominated impairment, group 2 – stiffness dominated impairment, group 3 – pain and stiffness causing impairment and group 4 – momentary pain causing impairment. Therefore, in a similar model to the APTA, patients with different struc tural pathology or medical diagnosis may be attrib uted to the same group. Patients with a given structural pathology or medical diagnosis may also be attributed to a different clinical group dependent upon the stage of the disorder. As an example, a patient with a medical diagnosis of subacromial impingement may present with signs or symptoms attributable to group 1 if there is an in ammatory component with their pain mechanism and there fore warrant very different physiotherapy treatment to a patient with the same medical diagnosis yet who has only momentary pain, for instance, when reaching into a particular position (group 4).
Other developments and cons iderations in the phys iotherapeutic management of s houlder conditions P hys iothe ra p y d ia gnos is a nd the c onc e p t of non-s p e c i c s hould e r p a in a nd s ub group ing c la s s i c a tion G iven the dif culties associated with the diagnoses of subacromial impingement and rotator cuff tendi nopathy, thought to be the principal cause of shoul der problems, alternative diagnostic terms such as ‘mechanical shoulder pain’ (Lewis 2007) or ‘nonspeci c shoulder pain’ have been proposed (Lewis 2009). Although such diagnostic labels clearly lie within the scope of practice of physiotherapy to utilize, these terms also fail to meet the requirement of a diagnosis as determined by the WCPT de ni tion as they fail to ‘guide physical therapists in determining the prognosis and most appropriate intervention strategies’(WCPT 2007). The issues surrounding the use of non speci c diagnostic cat egories have been well explored especially relating to low back pain (Fersum et al. 2010, O ’Sullivan 2005). It is a widely held belief amongst primary care clinicians, including physiotherapists, that
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within the broad diagnostic category of non speci c low back pain (NSLBP), there may be several smaller subsets of homogenous groups which may respond to a particular intervention speci c to that classi cation (Fersum et al. 2010). The search for such subgrouping classi cations has become a research priority within low back pain. A similar belief appears to be present relating to shoulder conditions (Sahrmann 2002, Lewis 2009, Aina & May 2005, McKenzie & May 2000). Although in its infancy there appear two discrete lines of scienti c enquiry relating to the subclassi cation of patients with general shoulder pain within physiotherapy practice. Firstly, classi cation systems have been developed based on clinical experience and expertise, some of which are summarized below (Sahrmann 2002, Lewis 2009, McKenzie & May 2000). Such classi cation systems now require sci enti c evaluation relating to their reliability and validity and therefore clinical applicability. Secondly, treatment based classi cation categories based on clinical presentation have shown promise in other body regions, for example the lumbar spine, through the development of clinical prediction rules (CPRs) (Stanton et al. 2010). There appear to be the early signs of similar developments relating to shoulder conditions (H ung et al. 2010), which are discussed in the section ‘Physiotherapy diagnosis and the concept of clinical prediction rules’.
• Sahrmann (2002) proposes a classi cation system based on ‘movement system impairments’. It is beyond the scope of this text to detail fully the concept and readers are directed to the companion text Diagnosis and Treatment o M ovement Impairment Syndromes by Sahrmann (2002) for a full explanation. In summary, diagnostic categories are named according to alignment or movement impairments, which when corrected abolish the patient’s symptoms, as opposed to the hypothesized pathoanatomical structural source (medical diagnosis). Assessment is therefore focused on identifying movements which reproduce pain as opposed to using special orthopaedic tests and imaging as used in the medical model. With regard to shoulder complaints, modi cations to static posture, humeral and scapular movement impairments are made in an attempt to abolish the patient’s symptoms. Modi cations which consistently abolish the pain form the diagnostic label and
basis for the treatment programme provided by the physiotherapist. • Lewis (2009) has proposed a ‘shoulder symptom modi cation procedure (SSMP)’ model. Again a full explanation of the proposal is provided in the original article. In a similar model to that proposed by Sahrmann (2002) mechanical procedures are applied to the scapula, humerus or cervical/ thoracic spine during a functional movement which most closely reproduces a patient’s shoulder pain in an attempt to reduce the patient’s pain. The procedure(s) which reduces the symptoms and/ or increases movement then forms the basis for the treatment programme undertaken by the physiotherapist. • McKenzie and May (2000) have proposed a classi cation system based on the application of mechanical diagnosis and therapy principles (which have been commonly applied to spinal conditions) to the peripheral joints including the shoulder complex. Classi cation categories of derangement, dysfunction and postural are based on a mechanical evaluation during which symptom response and mechanical response are evaluated (McKenzie & May 2000). Again, intervention is guided by the diagnostic category the individual patient is assigned to. Case studies by Aina and May (2005) and Littlewood and May (2007) demonstrate the utility of the approach. Common to all these proposed classi cation systems, at this stage, is an absence of research relating to the reliability and validity of each of the classi cation categories. Validation of classi cation systems such as these has been described as a multistep process and recommended as a requirement prior to their widespread use in clinical practice (Dankaerts et al. 2006). Furthermore, the complexities associated with the development of diagnostic classi cation currently evolving in physiotherapy have been well documented by numerous authors including Zimny (2004) and Foster et al. (2011). Issues such as subjectivity, the lack of mutually exclusive and dis tinct, yet exhaustive, categories, the degree of spe ci city of the categories and the limited scope and unidimensional nature of classi cation systems such as those proposed by Sahrmann (2002) and McKenzie & May (2000) have all been highlighted as challenges facing researchers in the attempt at diag nostic classi cation within physiotherapy (O ’Sullivan 2 17
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2005, Zimny 2004, Foster et al. 2011). As Foster et al. (2011) summarize with regard to the subgroup ing of low back pain ‘the true picture is that no sub grouping approaches have yet passed the various tests for clinical value and robustness of evidence’. Furthermore, ‘There is, as yet, a long way to go so be cautious of subgrouping approaches without robust evidence. The potential of this research to produce misleading results is high and attention to careful design issues is critical’ (Foster et al. 2011). The classi cation of shoulder conditions is even more in its infancy than the work relating to low back pain, and such comments are as equally if not more applicable. It is noteworthy, however, when reviewing these contemporary models of physiotherapy practice detailed above (Sahrmann 2002, Lewis 2009, McKenzie & May 2000), how closely associated the principles on which they are based are with the principles inherent to the Maitland Concept. In particular:
• The recognition paid to the dif culties, limitations and obstructions to patient management should physiotherapy treatment be directed by the medical diagnosis alone – a fundamental principle central to the Maitland concept discussed further in the section ‘Diagnosis and the Maitland concept’. • The use that the Maitland concept makes of patients’ functional movements with which they are able to demonstrate their disability or disorder and/ or provocation of pain (Maitland 1986). • The importance paid to assessment; ‘assessment has always been the keystone of this text, even during the writing of the rst edition in 1964’ (Maitland 1986). A logical and methodical process of assessing cause and effect are the demands of the Maitland concept whereby proof of whether treatment is working or not which is achieved by continually comparing the effects of the selected and progressed treatment techniques on the patients symptoms and signs (clinical proof). • Flawless analytical assessment which is considered the keystone to the Maitland concept (Maitland 1986).
P hys iothe ra p y d ia gnos is a nd the c onc e p t of c linic a l p re d ic tion rule s A second line of recent scienti c enquiry within physiotherapy that has generated much interest, and 2 18
a recent surge of research activity, relates to the ability to identify patients who respond best to a certain treatment. Indeed, with respect to shoulder problems, from a research perspective, it has been suggested that study of a broad heterogeneous popu lation with ‘general shoulder pain’ may allow the identi cation of subsets of individuals with common characteristics which possess important treatment and prognostic implications (May et al. 2010, Schellingerhout et al. 2008). Clinical prediction rules (CPRs) are designed to improve clinical decision making, and have been developed in establishing a diagnosis, prognosis and in matching individuals to a particular intervention. Recently within physiotherapy practice, clinical pre diction rules have been developed, which aim to assist the clinical decision making process with regard to treatment selection including as examples studies by Cleland et al. (2007), Currier et al. (2007), Flynn et al. (2002), H icks et al. (2005), Vicenzino et al. (2010). Recently, H ung et al. (2010) have proposed a classi cation strategy for patients with a clinical diagnosis of ‘subacromial impinge ment syndrome’. A prediction method based on three variables of scapular kinematics and impair ment features was developed in order to predict improvement at six weeks following a standardized intervention regime including manual therapy, RO M exercise, stretching and strengthening exercise (H ung et al. 2010). Although clinical prediction rules offer the potential to become a valuable clinical tool which in uence decision making and improve outcomes in physiotherapy practice, particularly relating to treatment selection, it is important they are devel oped and fully validated prior to being applied clini cally (Stanton et al. 2010, Childs & Cleland 2006). A full explanation of the validation proposal is provided by Childs & Cleland (2006) and Stanton et al. (2010). In a recent systematic review of 15 CPRs developed for assisting treatment selection in musculoskeletal conditions which have been developed to date, Stanton et al. (2010) urge caution with the clinical application of all but one CPR (spinal manipulation for low back pain) (Flynn et al. 2002, Childs et al. 2008, Cleland et al. 2007). O f the 15 CPRs studied only one had reached the validation stage (step II of III) with the other 14 CPRs at the derivation stage of development (step I of III). Numerous other methodological issues, particularly relating to the study design, support the contention that these published CPRs
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should not be used to predict treatment effects in clinical practice at this stage (Stanton et al. 2010). Nonetheless, with the appropriate rigorous meth odological development, analysis and validation, CPRs offer the potential to assist the identi cation of subsets of patients who will respond to a given intervention strategy, thereby assisting in the clinical decision making process of physiotherapists in rela tion to patient treatment.
Integration of the Maitland Concept into contemporary phys iotherapy practice relating to s houlder conditions Figure 4.24 demonstrates a triage process which may be used by physiotherapists when assessing
an individual presenting with a shoulder disorder. Although it is not within the scope of physiothera pists to be medical diagnosticians they must possess the ability, equally as important as for ESPs, to rec ognize clinical presentations which require early medical attention. Details of the clinical presenta tion of such cases are discussed in the sections ‘The importance of screening for red ags’, ‘Screening for conditions which require early medical attention’, and ‘Screening for extrinsic sources – analytical assessment and differentiation’. O nce the patient is screened for such present ations the focus of assessment aims to identify physical impairments which are the cause of or con tribution to a patient’s functional limitations and hypothesize where possible the underlying reasons for their presence. It is then the intervention, analytical assessment and meticulous reassessment of effect which drives further examination,
Screen for red flags
Screen for conditions which require early medical attention
Screen for extrinsic sources
Establish the individuals abilities, disabilities, functional limitations and underlying impairements
• Tumour? – Hx of cancer, symptoms and signs of cancer, unexplained deformity, mass or swelling; lymphadenopathy. Progressive, welllocalized pain, unrelated to movement, often night predominant, not reproduced by palpation or movement during examination • Infection? – Red skin, fever, systematically unwell • Neurological lesion? – Unexplained wasting, significant sensory or motor deficit • Pulmonary or vascular compromise?
• Acute rotator cuff tear? – Recent trauma, acute disabling pain and significant weakness, positive drop arm test • Unreduced dislocation? – Trauma, epileptic fit, electric shock, loss of rotation, abnormal shape • Young adult with acute traumatic primary anterior shoulder dislocation • Undiagnosed severe shoulder pain
• Cervical spine disorders • Thoracic spine disorders • Nerve disordersradiculopathy, brachial neuritis (also known as neuralgic amytrophy, Parsonage-Turner syndrome), Thoracic outlet syndrome, Nerve entrapments inc. suprascapular, long thoracic nerve • Inflammatory disorderspolymyalgia rheumatica, rheumatoid arthritis • Visceral disordersheart, lungs, gallbladder, diaphragm, spleen, kidney • Complex regional pain syndrome
Clinical reasoning process where clinical evidence is given primacy but considered in conjunction with the theorectical hypotheses Theoretical hypothesis to consider Biomedical diagnosis (see section 4 and in particular tables 4.8–4.15) Pain mechanisms, Tissue sources, Anatomy Physiology Pathology
Clinical facts considerations History Symptoms Signs-specific physical impairments identified through clinical examination
Fig ure 4.24 • Integrating the Maitland Concept into contemporary physiotherapy practice relating to shoulder conditions. 2 19
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physiotherapy diagnosis and patient management (Maitland et al. 2005). Clinical reasoning models such as those proposed by Jones and Rivett (2004, p 4) provide a framework on which decisions regard ing a patient’s physiotherapy management and prog nosis are based. Readers are encouraged to adopt such a patient centred model of clinical reasoning to underpin their practice in combination with the use of hypotheses categories on which management decisions can be developed. The utility of the Maitland Concept in the man agement of shoulder conditions appears as attractive today as when rst developed particularly when considering the de ciencies of a pathologically based model, that scienti c enquiry has discovered. Indeed, it is particularly interesting to consider recommendations in contemporary literature advo cating conservative treatment of shoulder problems to be ‘guided by the response to symptom modi cation’ (Lewis 2009), ‘signs and symptoms (H ughes et al. 2008) and ‘based on symptom response’ (May et al. 2008). It appears that ‘ the unique approach to clinical practice with the prin ciples as worked out by Maitland more than four decades ago still seems applicable at the beginning of the twenty rst century’ (H engeveld & Banks 2005). We must continue to await further scienti c enquiry and development especially with regard to the development of a categorization system to identify subgroups of patients with shoulder prob lems who may respond to a speci c intervention.
The s ymb olic p e rme a b le b ric k wa ll The unique mode of thinking advocated in the Maitland Concept, epitomized by the symbolic permeable brick wall remains an important corner stone in physiotherapy practice. ‘This thinking mode is not used in any other philosophy of manipulative therapy’, which is a ‘demand requirement’ of the Maitland Concept and ‘the security of the therapist whose primary concern should be the importance of the clinical compartment in the decision making process’(Maitland 1991, Maitland et al. 2005) has been previously discussed speci cally in the section ‘Diagnosis and the Maitland Concept’ earlier in this chapter. The requirement for the continued use of this mode of thinking by physiotherapists in con temporary practice is clear when considering the potential limitations and problems should physio therapy treatment be directed by the biomedical diagnosis and diagnostic titles of shoulder conditions 220
as has been previously discussed in the section ‘The biomedical perspective’ and throughout this chapter. Figure 4.24 illustrates the integration of the brick wall into the triage process, speci cally with regard to the category concerned with establishing the indi vidual’s abilities, disabilities, functional limitations and underlying impairments relating to their shoul der problem. It must be remembered that the brick wall model can be applied equally to the rst three categories concerned with screening the shoulder complex for signs of serious pathology, conditions which require early medical attention and have extrinsic sources.
Integrating evidence from Tables 4.8–4.15 into clinical physiotherapy practice using the brick wall model The information relating to the biomedical diagnos tic titles of some of the more common shoulder conditions presented in Tables 4.8–4.15 can be considered within the brick wall model. Figure 4.25 serves to illustrate this contention. Two clinical examples serve to highlight the bene ts of such an approach. 1. Consider the patient referred to physiotherapy with a diagnosis of subacromial impingement. Tables 4.8 and 4.9 would help support the knowledge to form the left side of the brick wall (theory). With in depth understanding of the concept of this condition physiotherapists are able to recognize the limitations of the diagnostic title and recall the vast array of possible underlying pathology and varying clinical presentations and impairments that may be associated with such a diagnostic title. In the words of Maitland: It becomes apparent that if one is to base treatment on diagnosis alone, one must be aware of the real dif culties associated with making it precise and therefore meaningful. And: ‘it is not the diagnosis which indicates the kind of passive movement treatment required; it is the behaviour of the symptoms and signs during movement. This means that the symptoms and signs (the right compartment) combined with the knowledge of anatomy, biomechanics, pathology and the diagnosis (the left hand side of the compartments) guide the selection of initial treatment … such a plan avoids both the confusion caused by diagnostic titles calling to
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Theoretical Biomechanics Anatomy Neurophysiology Biomedical engineering Pain science Research Medical diagnosis Shoulder conditions i.e. Table 4.8 Rotator cuff lesions (inc table 4.10 calcifying tendonitis and 4.10 shoulder impingement) Table 4.11 Frozen shoulder Table 4.12 Glenohumeral osteoarthritis Table 4.13 SLAP lesions Table 4.14 Shoulder instability (functional/structural) Table 4.15 acromioclavicular lesions (osteoarthritis/ injury) Table 4.8-4.15 headings within each diagnostic category inc. “brief overview”; “Onset and aetiology”; “pathology”; “clinical presentation”; Medical diagnostic considerations”; “associated conditions”; “management”; “implications for physiotherapists”; “evidence sources (examples)” Extrinsic conditions Table 4.5 Peripheral nerve entrapments around the shoulder Table 4.6 Spinal conditions Table 4.7 Other possible extrinsic sources of shoulder pain and dysfunction
Speculative Often abstract
Clinical The individual patient; Functioning (ICF) Activity limitations Participation restrictions (disability) History Symptoms Signs Impairments
Factual, concrete
Fig ure 4.25 • An example o how the brick wall model can be used to integrate the evidence and knowledge presented in Tables 4.8–4.15 (which detail the most common conditions a ecting the shoulder) into physiotherapy practice. The theoretical knowledge relating to the medical diagnoses o shoulder conditions orms the le t side o the wall, with the clinical acts relating to the individual patient’s case orming the right side o the wall.
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mind different symptoms to different people and the controversy over pathology. Maitland (1986)
2. Consider the patient presenting with shoulder pain and dysfunction where numerous physical impairments have been identi ed but have not been able to be modi ed with physiotherapy treatment, or following correction have not led to improvement in the patient’s functional limitations. Knowledge of conditions which may prove less amenable to conservative treatment such as a SLAP lesion (Table 4.8) in a young, athletic individual, using Maitland’s contention of ‘making the features t’ would allow the physiotherapist to recognize such a clinical presentation. Referral for further biomedical diagnostic evaluation would therefore be able to be arranged in a timely manner.
Orthopaedic special tests – a reinterpretation and rede nition with respect to the Maitland Concept and the brick wall model The orthopaedic special tests detailed and discussed in the section ‘Diagnostic accuracy – a brief review’ can also be considered within the two compartment mode of thinking and be integrated into contem porary physiotherapy clinical decision making. As previously discussed and summarized in Table 4.1, in general, the orthopaedic special tests do not possess satisfactory diagnostic accuracy to establish a biomedical diagnosis. Nonetheless, during per formance of these tests it is possible that the patient’s comparable shoulder pain may be repro duced. Furthermore, the positions used in such special tests may relate to the patient’s functional problems and hence allow the identi cation of movement impairments in the shoulder complex. This assists the physiotherapist in discovering the source and cause of the symptoms and facilitates the physiotherapist in their clinical decision making regarding the treatment of the individual in a way which addresses the movement impairment (and hence special tests) with the aim of improving the patient’s associated functional limitation. The clinical information on the right side of the permeable brick wall can be used as physical examination asterisks for reassessment and/ or as examination and treatment techniques from a movement analysis point of view. So, for example, 222
the H awkins–Kennedy test can be considered as an assessment of shoulder internal rotation in dif ferent positions of horizontal adduction and abduc tion. Considering the tests or movement procedures in this manner allows them to be integral to the Maitland Concept whereby they analyze movement rather than being diagnostic speci c. This approach also allows the ‘orthopaedic special tests’ to be utilized as treatment techniques for pain, stiffness or spasm in these functional positions and as examination of movement procedures. The Mait land Concept also emphasizes the prime importance of assessment and, indeed, when performing these techniques assessment during and after the treat ment is essential to determine whether the pro cedure is bene cial to the patient and their functional limitation or not. If, for example, mobi lization into medial and lateral rotation, under axial compression in elevation (the Crank test) aggra vated the symptoms and did not produce any improvement in movement the treatment would be considered inappropriate. Table 4.16 below demonstrates how examples of orthopaedic special tests can be interpreted from a movement impairment perspective as opposed to a medical diagnostic perspective utilizing the brick wall concept and consequently can be utilized within physiotherapy practice. Note how the theory of the orthopaedic special tests can be translated into clini cal facts.
P hys iothe ra p y e xa mina tion, a s s e s s me nt a nd tre a tme nts of s hould e r d is ord e rs Box 4.2 provides a summary of the subjective ex amination of the shoulder and shoulder girdle com plex. Boxes 4.3-4.9 (inclusive) provide a summary of the physical examination of each of the constitu ent components of the shoulder girdle complex. Information gathered from the subjective and phys ical examination serves to complete the right side of the brick wall and forms the basis on which physiotherapy management decisions are primarily based (the primacy of clinical evidence), in combi nation with information from the left side of the wall (Tables 4.8–4.15). The technical performance of physical examination (and treatment) tech niques, including physiological and accessory mobi lizations are demonstrated on the accompanying Maitland’s website It is also worth recalling a perti nent quote from the fourth edition of M aitland’s Text continued on p. 232
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Table 4.16 A reinterpretation o special orthopaedic tests with respect to the Maitland Concept and the brick wall model Theory (known, unknown, think we know)
Clinical ( acts)
Pain or weakness on the empty can test may serve as a conf rmatory test or impingement/supraspinatus tear.
In 90° scapular elevation, resisted elevation internal rotation is pain ul and/or weak.
Pain ul Hawkins–Kennedy test maybe use ul as a screening test or impingement or supraspinatus tendonitis.
Internal rotation o the arm in 90° scapular elevation is pain ul.
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Table 4.16 A reinterpretation o special orthopaedic tests with respect to the Maitland Concept and the brick wall model—cont’d Weakness demonstrated by the Hornblower’s test may be diagnostic o severe degeneration or absence o the teres minor muscle.
Resisted external rotation o the arm in 90° scapular elevation and 90° elbow exion is weak (pain inhibition?).
External rotation lag sign maybe diagnostic o an in raspinatus or rotator cu muscle tear.
With the elbow at 90° and the arm in 20° scapular elevation, external rotation is weak.
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Table 4.16 A reinterpretation o special orthopaedic tests with respect to the Maitland Concept and the brick wall model—cont’d Belly press test may assist ruling in a subscapularis tear.
Resisted internal rotation o the arm is weak.
Increased apprehension or symptom response with the Biceps load I and II tests may indicate a SLAP lesion.
Resisted elbow exion (in supination) in 90° and 120° abduction and ull external rotation is pain provocative.
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Table 4.16 A reinterpretation o special orthopaedic tests with respect to the Maitland Concept and the brick wall model—cont’d Pain, catching or clicking during the Crank test could indicate a labral lesion.
In elevation, internal and external rotation o the arm under axial compression is pain ul.
Deep pain or pain ul clicking during O’Brien’s test could indicate a labral lesion.
In 90° rontal elevation, 15° horizontal adduction and ull internal rotation, resisted elevation is pain ul.
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Box 4 2 Subjective examination o the peripheral joints The arrangement of the s ubjective examination is bas ically the s ame for all joints and is therefore only s et out in detail for the glenohumeral joint
•
‘Kind ’ of d is ord e r • •
Start with rs t mandatory ques tion (‘Ques tion 1’) Es tablis h why the patient has been referred for or s ought treatment: a pain, s tiffnes s , giving way, ins tability, weaknes s , los s of function, etc b pos ts urgical, trauma, MUA, plas ter, fracture, dis location, etc
His tory 1 Of this attack 2 Previous his tory
Check as s ociated areas : a of vertebral column b of joints ‘above and below’ the les ion c other relevant joints
Be ha viour of s ymp toms 1 When are they pres ent or when do they vary? (cons tant, intermittent – frequency) 2 What provokes , what relieves ? 3 Any pain at night? Need to get up becaus e of it? Able to lie on it? (Is the night pain for mechanical reas ons or in ammatory? ) 4 On rs t ris ing c f end of day 5 Functional limitations (dominance of pain, s tiffnes s , weaknes s , etc )
3 Socioeconomic his tory as applicable 4 Are the s ymptoms wors ening or improving? 5 Any previous treatment? Effect? 6 Any contraindications ? Highlight m ain f ndings with asterisks
Are a • •
Is the dis order one of pain, s tiffnes s , ins tability, weaknes s ? Record on the body chart: 1 area and depth of s ymptoms indicating main areas and s tating type of s ymptoms 2 paraes thes ia and anaes thes ia
Sp e c ia l q ue s tions 1 General health, relevant weight los s (medical his tory) 2 What tablets are being taken for this and other conditions ? (s teroids , painkillers , antiin ammatory drugs )
Planning the phys ical examination ‘Planning the phys ical examination’ is included as part of the total examination procedure as a teaching medium to encourage clear, methodical and purpos eful thinking It is the s tep taken, after the s ubjective examination, to formulate the requirements of the phys ical examination
Reproduced by kind permission rom Maitland GD (1991) Peripheral Manipulation 3rd ed. Ox ord: Butterworth-Heinemann, p 291.
Box 4 3 Physical examination o the composite shoulder Ob s e rva tion
Brie f a p p ra is a l
*Functional demons tration/tes ts
Active movements (move to pain or move to limit)
•
• • •
•
Their demons tration of their functional movements affected by their dis order Differentiation of their demons trated functional movement(s )
F (s pontaneous then s agittal) Ab (s pontaneous then coronal) HF, HE
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Box 4 3—cont’d • •
Behind back (wris t mid-line) F and Ab in medial and lateral rotation
3 S/C joint: as applicable ceph and caud, , , Rotn, dis traction and compres s ion (repeat rs t ve with compres s ion)
Is ometric tes ts •
4 Slump tes ts
Cuff
5 Differentiation tes ts 6 ULNT
Other s tructures in ‘plan’ • • •
Thoracic outlet Entrapment neuropathy ULNT
Prone • •
Pas s ive movements
Hand behind back, E, Ad, Forehead res ting in palms , G/H, , cervical and
As indicated by s ite of pain and s tiffnes s
S ide lying
S upine
•
1 G/H joint F, Ab,
,
, HF, HE or Q and locking pos ition
Arm-by-s ide, , , (gapping G/H joint) Arm abducted, Arm in F/Q, ,
caud and ceph, caud, , caud (and ceph)
2 A/C joint: s queeze, , ,
, caud,
Scapulothoracic: as applicable El, De, Protr, Retr, Rotn; as applicable add compres s ion
Palpation •
+ When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ Check cas e records , etc Highlight m ain f ndings with asterisks Ins tructions to patient
, caud and ceph, Rotn
(repeat with compres s ion) Reproduced by kind permission rom Maitland GD (1991) Peripheral Manipulation 3rd ed. Ox ord: Butterworth-Heinemann, p 291.
Box 4 4 Glenohumeral joint – objective examination What is s ometimes referred to as an ‘acces s ory joint’, between the head of the humerus and the acromion proces s , forms part of the examination of the glenohumeral joint
Brie f a p p ra is a l
HIGHLIGHT MAIN FINDINGS WITH ASTERISKS AS YOU GO
Ac tive move me nts
Ob e rva tion Watch for patient’s willingnes s to move the arm when undres s ing
Func tiona l d e mons tra tion/te s ts As a p p lic a b le 1 Their demons tration of their functional movements affected by their dis oder 2 Differentiation of their demons trated functional movement(s )
228
Note abnormalities of appearance, tendernes s , temperature and fas ciculation Palpation may be performed here
Active quick tes ts (+ cervical) Rou tin e ly (with all joints , always modi ed to s uit ‘kind of dis order’) F, Ab, (note ‘drift’), behind back, HF Note range, pain, repeated, and behaviour (note s capular rhythm)
As a p p lic a b le Speed of tes t movements Speci c movements which aggravate The injuring movement Movements under load
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Box 4 4—cont’d Thoracic outlet tes ts & ULTT Mus cle power F & Abd in full medial & lateral rotation
Is ome tric te s ts
Ac c e s s ory m ove m e n ts As a p p lic a b le May be as s es s ed at rs t s es s ion or as treatment progeres s es : 1 By thumb pres s ures or arm leverage , , caud and ceph, , laterally: (a) In different pos itions in the range (b) With addition of compres s ion and/or dis traction
Rotator cuff Other mus cles in ‘plan’
Othe r s truc ture s in ‘p la n’ Cervical s pine J oints ‘above and below’ Thoracic outlet & ULNT
Physiological m ovem ents
2 Mid range Ab/Ad, Rotn, and F/E os cillations : (a) With glenohumeral compres s ion (b) With acromiohumeral compres s ion 3 1s t rib Note range, pain, res is tance, s pas m and behaviour
Rou tin e ly
P a lp a tion
P a s s ive move me nts
1 If pain s evere , pain-free pos ition)
Caudad,
lateral; (in neutral
2 F , , Ab, HF, HE, components of hand behind back and (if active tes ts pos itive) or 3 Quadrant and locking pos ition (if active tes ts negative) Note range, pain, res is tance, s pas m and behaviour
Temperature Relevant tendernes s (caps ule, tendons , burs ae, mus cles ) Swelling, Was ting Altered s ens ation Pos ition When ‘comparable s igns ’ ill – de ned reas s es s ‘injuring movement’
Che c k c a s e re c ord s a nd ra d iogra p hs
As a p p lic a b le
Ins tructions to patients
1 Canal’s s lump tes ts 2 Differentiation tes ts 3 ULNT (upper limb neural tes ts )
1 Warning of pos s ible exacerbation 2 Reques t to record details 3 Ins truction re ‘joint care’ if required
Reproduced by kind permission rom Maitland GD (1991) Peripheral Manipulation 3rd ed. Ox ord: Butterworth-Heinemann, p 291.
Box 4 5 Physical examination o the acromiohumeral joint The routine examination of the acromiohumeral (A/H) joint mus t include examination of the acromioclavicular joint and the glenohumeral joint
Differentiation tes ts (s upine) •
Differentiating A/H joint:
1 from rotator cuff
Ob s e rva tion *Functional demons tration/tes ts • •
Their demons tration of their functional movements affected by their dis order Differentiation of their demons trated functional movement(s )
Brie f a p p ra is a l Active movements (move to pain or move to limit) Is ometric tes ts
It is A/H if: a is ometric 30° Ab reproduces s ymptoms b there is no pain with os cillatory Ab at 30° if A/H joint is dis tracted caudad 2 rom G/H joint – os cillatory Ab (from 20° to 40°): It is A/H if: a painful when A/H s urfaces compres s ed and moved b painles s when A/H dis tracted caudad and moved c painles s when G/H compres s ed and A/H dis tracted during movement
229
C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
Box 4 5—cont’d 3 from A/C joint It is A/H if: a HF, −ve b clavicular head −ve
Other s tructures in ‘plan’ •
Thoracic outlet
Pas s ive movements (s upine) •
Tes t movements 1–3 below s hould: a reproduce the s ymptoms when the humerus is compres s ed agains t the interior s urface of the acromion proces s , compared with b being painles s when the head of the humerus is dis tracted caudad from the acromion proces s
3 Os cillatory Rotn, in s light Ab (30° arc in mid-range) c caud on acromion or clavicular head: • reproduce pain when A/H s urfaces compres s ed (A/C movement nil) • are painles s when A/H s urfaces dis tracted while A/C movement is produced As applicable 1 Slump tes ts 2 Differentiation tes ts 3 ULNT
Palpation • •
1 Os cillatory Ab (from 20° to 50°) 2 Os cillatory F/E, in s light Ab (from 0° to 30°)
As previous ly + When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ Check cas e records etc Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission rom Maitland GD (1991) Peripheral Manipulation 3rd ed. Ox ord: Butterworth-Heinemann, p 291.
Box 4 6 Physical examination o the acromioclavicular joint When examining the acromioclavicular joint (A/C), the G/H, A/H and S/Th movements mus t be examined
Note range, pain, repeated (note s capular rhythm) As applicable
Ob s e rva tion *Functional demons tration/tes ts • •
Their demons tration of their functional movements affected by their dis order Differentiation of their demons trated functional movement(s )
Brie f a p p ra is a l Active movements (move to pain or move to lim it) Routinely 1 G/H F, Ab, behind back, HF and HE 2 Scapular elevation, depres s ion, protraction, retraction and rotation
230
• • • •
Speed of tes ts movements Speci c movements which aggravate The injuring movement Movements under load
Is ometric tes ts • •
Rotator cuff Other mus cles in ‘plan’
Other s tructures in ‘plan’ •
Thoracic outlet
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Box 4 6—cont’d Pas s ive movements Physiological m ovem ents Routinely 1 G/H F, Ab, , , HF and HE or Q and locking pos ition 2 Scapular elevation, depres s ion, protraction, retraction and rotation Note range, pain, res is tance, s pas m and behaviour
Accessory m ovem ents Routinely 1 By thumb pres s ure , , ceph and caud a over acromion b over clavicle c on the joint line d repeat with joint compres s ed
2 Squeeze clavicle and s capula 3 Rotation at S/C and A/C joints a trans vers e axis b vertical axis (by s capular protraction/retraction) 4 As for G/H joint 5 Slump tes ts 6 Differentiation tes ts 7 ULNT
Palpation •
+ When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ Check cas e records etc Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission rom Maitland GD (1991) Peripheral Manipulation 3rd ed. Ox ord: Butterworth-Heinemann, p 291.
Box 4 7 Physical examination o the sternoclavicular joint When examining the s ternoclavicular (S/C) joint the A/C joint (including relevant G/H, A/H and S/Th movements ) mus t als o be examined
Pas s ive movements Physiological m ovem ent
Ob s e rva tion
1 Supine: G/H, HF, HE and F 2 Side lying: s capular elevation, depres s ion, protraction, retraction and rotation Note range, pain, res is tance, s pas m and behaviour
*Functional demons tration/tes ts • •
Their demons tration of their functional movements affected by their dis order Differentiation of their demons trated functional movement(s )
Routinely
Accessory m ovem ent Rroutinely •
Brie f a p p ra is a l Active movements (move to pain or move to limit) Routinely 1 G/H F, HF and HE 2 Scapular elevation, depres s ion, protraction, retraction and rotation Note range, pain and repeated
Is ometric tes ts Other s tructures in ‘plan’ •
Thoracic outlet
• •
By thumb pres s ures on clavicle , , , caud and ceph, rotation, dis traction and compres s ion Note range, pain, res is tance, s pas m and behaviour As applicable Add compres s ion (medial and caud) to above ULNT
Palpation •
+ When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ Check cas e records etc Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission rom Maitland GD (1991) Peripheral Manipulation 3rd ed. Ox ord: Butterworth-Heinemann, p 291.
231
C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
Box 4 8 Physical examination o scapulothoracic movement When examining s capulothoracic dis orders the glenohumeral (G/H) joint mus t als o be examined
Ob s e rva tion *Functional demons tration/tes ts •
Their demons tration of their functional movements affected by their dis order Differentiation of their demons trated functional movement(s )
Other s tructures in ‘plan’ • •
Thoracic outlet Entrapment neuropathy
Pas s ive movements Physiological m ovem ents Routinely
Active movements (move to pain or move to limit)
1 G/H movements 2 Side lying: s capular elevation, depres s ion, protraction, retraction and rotation (add compres s ion as applicable) Note range, pain, res is tance, s pas m and behaviour As applicable
Routinely
1 Slump tes ts
1 G/H F, Ab, behind back, HF 2 Scapular elevation, depres s ion, protraction and retraction Note range, pain and s capular rhythm As applicable
2 Differentiation tes ts 3 ULNT
•
Brie f a p p ra is a l
• • • • •
Speed of tes ts movements Speci c movements which aggravate The injuring movement Movements under load Mus cle power
Is ometric tes ts • •
Rotator cuff Other mus cles in ‘plan’
Accessory m ovem ents Routinely 1 Intercos tal movements 2 Lifting s capula off thorax Note range, pain, res is tance, s pas m and behaviour
Palpation •
+ When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ Check cas e records etc Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission rom Maitland GD (1991) Peripheral Manipulation 3rd ed. Ox ord: Butterworth-Heinemann, p 291.
Peripheral M anipulation when considering issues relating to the physiotherapy examination of shoul der disorders: The ultimate aim of dealing with musculoskeletal disorders is to fully restore the patient’s pain free active functional movement. The initial aim of physical examination therefore is to identify the active functional movements which are not full and pain free (Fig. 4.26). Passive movements tested both through the available range and at the limit of the available range and which are found to be impaired by pain, stiffness or protective spasm can then form the basis of treatment techniques. This should include mobilization of joints, lengthening of contracted or brosed muscle and restoration of ideal neurodynamics. Hengeveld & Banks 2005
232
De mons tra tion through c a s e s tud ie s The case studies that follow serve to demonstrate the physiotherapy management of a broad range of presentations of patients with shoulder pain and dysfunction utilizing principles inherent to the Mait land Concept. Speci cally the cases serve to high light the importance of dealing with musculoskeletal pain and dysfunction at face value, addressing iden ti able physical impairments thought to contribute to an individual’s functional limitations. Readers are again encouraged to cross reference the techniques utilized in the treatment of each case with the dem onstrations provided in the video clips that accom pany this chapter.
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Box 4 9
Reproduction of symptoms producing comparable signs
Physical examination o costal joints and intercostal movement
Detecting abnormal movements and movement directions (impairments - movement dysfunctions)
Thoracic intervertebral joints s hould form part of the examination
Ob s e rva tion
Differentiate components of the impaired movement dysfunctions - movement diagnosis
*Functional demons tration/tes ts • •
Their demons tration of their functional movements affected by their dis order Differentiation of their demons trated functional movement(s )
Brie f a p p ra is a l Active movements (move to pain or move to limit)
MAY analyze structures - recognise the limitations associated with the ability of clinical examination to identify structural shoulder pathologies
Fig ure 4.26 • Algorithm o physical examination objectives. Modif ed rom Hengeveld & Banks 2005 .
Routinely 1 Ins piration and expiration, to maximum, quickly 2 Trunk F, E, LF, Rotn in F and E
Accessory m ovem ents , , , , adding ceph and caud and other varying angles Note range, pain, res is tance, s pas m and behaviour
Palpation •
•
For intercos tal and thoracic inters pinous s pacing, prominence and thickening 3 Full s capulohumeral F through F and Ab 4 Side lying: arm through Ab to full exion pos ition 5 ULNT and cervical/thoracic s lump Note range, pain and behaviour As applicable
• The limitations and problems associated with
•
The injuring or aggravating movements
Is ometric tes ts Other s tructures in ‘plan’ Pas s ive movements
•
Physiological m ovem ents Routinely As for ‘routine active movements ’ above, with overpres s ure and localizing •
When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ Check cas e records etc Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission rom Maitland GD (1991) Peripheral Manipulation 3rd ed. Ox ord: Butterworth-Heinemann, p 291.
• • •
allowing physiotherapy treatment to be primarily in uenced by theory (the le t side o the permeable brick wall): ○ Readers are directed to review Case study 4.3. The importance o assessing or shoulder symptoms sourced in the spine: ○ Readers are directed to review Case study 4.4. ○ See also Case study 4.5. Dealing with a shoulder problem with multiple physical impairments and components: ○ Case study 4.6. ○ Case study 4.7. ○ Case study 4.8. Dealing with a pain ul shoulder: ○ Case study 4.9. Dealing with a sti shoulder: ○ Case study 4.10. Dealing with a shoulder which proves resistant to physiotherapy treatment: ○ Readers are directed to review Case study 4.4. 233
C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
Cas e s tudy 4 5 The importance o assessing or shoulder symptoms sourced in the spine Mrs M, a 48-ye a r-old c a fé owne r Kind of dis order •
•
•
Pain in the region of the left s houlder, particularly troubles ome when trying to reach into cupboards above s houlder height at work Mrs M was referred to phys iotherapy by an orthopaedic cons ultant s urgeon with a m edical diagnosis of ‘moderate s ubacromial impingement’.
Body chart features (Fig 4 27) • •
Felt as a dull aching s ens ation mos t of the time, and A s harper pain pres ent intermittently In addition, following dis cus s ion a third area of s ymptoms came to light with a report of a dull aching s ens ation felt in region
Activity limitations /24-hour behaviour of s ymptoms •
•
Increas es when attempting elevatory activities s uch as reaching into cupboards in her café and dres s ing with s uperimpos ed , s ettles within a ‘couple of mins ’ when placing arm by s ide Increas es when carrying, for example, when s erving in her cafeé (trays ), builds as day progres s es but s he was able to continue at work des pite the pain ( ve hour s hifts , ve days per week)
Pres ent and pas t his tory • •
The s houlder pain and had been pres ent for approximately *18 months , developing ins idious ly *Six months prior to the development of the pain in the region of the s houlder, s he mentioned having s uffered a fall onto her left s ide following a s lip on ice She recalled s uffering s ome bruis ing to her left
upper arm and general s orenes s both of which s ettled over a couple of weeks Following dis cus s ion, Mrs M was able to recall intermittently s ens ing an aching s ens ation in area for *‘a few years ’ although it was not particularly troubles ome to her and s he had never s ought help
Patient journey to phys iotherapy Mrs M had initially contacted her GP who arranged treatment in phys iotherapy approximately 10 months into the cours e of the s houlder pain Unfortunately, Mrs M felt that this cours e of phys iotherapy s erved only to aggravate her s ymptoms and a mutual decis ion was made between the phys iotherapis t and patient to dis continue treatment after s ix s es s ions Mrs M des cribed the treatment as cons is ting predominantly of s houlder exercis es , which s he was taught to undertake at home us ing a theraband (patient s imulated internal rotation or external rotation movement with her arm by her s ide) Her GP chos e then to make the referral to the orthopaedic cons ultant, whom in turn recommended a further cours e of phys iotherapy having diagnos ed ‘moderate s ubacromial impingement’ The patient expres s ed frus tration at her lack of progres s thus far, although agreed to a further cours e of treatment in phys iotherapy She was us ing paracetamol prn for the s houlder pain, and reported no other ill health
Phys ical examination (pertinent ndings ) Observation Slight forward head pos ture, mild dowager’s , noticeable thoracic kyphos is
Functional dem onstration Left s houlder elevation AROM – full range of movement, increas e 1 at 110° to EOR + in Cx RSF no effect 1 + in wris t ext no effect 1
Fig ure 4.27 • Body chart o Mrs M.
1 Dull ache, most of the time, deep
2 Sharper, intermittent, deep
234
3 Dull ache, intermittent, deep
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Cas e s tudy 4 5—cont’d + AH compres s ion increas e 1 + T1, T2 reduction 1
as required dependent upon res pons e to initial treatment
Active m ovem ent
Day 1,Rx1
Shoulder abduction – full range of movement, increas e 1 at 110° to EOR Shoulder LR 50° increas e 1 40° to EOR Cervical RR, LR, RSF, LSF, full range pain free *Cervical retraction OP 3 EOR Lower Cx combined E +LSF+LR mild res triction R2 , no effect , ,
T1 and T2 grade III producing a mild degree of local dis comfort, for 4 mins , prone, s houlder neutral Reas s es s ment: Shoulder elevation full range, increas e 1 only at 160° (prior to Rx 110°)
Passive m ovem ent GH elevation as AROM full range achievable, increas e 1 110° to EOR AH compres s ion in 90° abduction/elevation NAD Unilateral and PA examination cervical s pine – s tiff left C7 later range, other NAD *PA unilateral T1, T2 local pain, s tiff, local pain limited mid-range, no effect , , * T1, T2 local pain, R2 mid-range, no provocation , , *Unilateral rib 2 local pain, s tiff, local pain limited midrange
Other tests Painfull Hawkins –Kennedy impingement tes t, empty can and full can tes ts painful and weak Is ometric lateral rotation pain provocative increas e 1
Analys is Strong s timulus res pons e relations hip s till evident, indicative or s ugges tive of dominant nociceptive pain mechanis m Functional limitations of lifting or carrying and with pain during elevatory activities Incons is tent res pons e noted to movements purported to implicate the s ubacromial tis s ues – pos itive OSTs , pos itive AH compres s ion in functional demons tration, but NAD in controlled pas s ive tes ting procedure Limitations as s ociated with the biomedical diagnos es of s ubacromial impingement acknowledged ? s ymptoms and being maintained els ewhere Impairment to T1, T2 acces s ory motion in trans vers e, unilateral direction noted, and impairment to acces s ory motion unilateral rib 2
Plan Addres s the impairment to acces s ory motion at T1, T2 and rib 2 with meticulous reas s es s ment of the effect on the functional limitations , initially primarily pain as s ociated with through-range s houlder elevation and abduction Cons ider further as s es s ment of s houlder complex impairments or neurodynamics
Day 6,Rx2 Felt much better Res olution of cons tant 1 to intermittent with s ame activities Noticeable reduction frequency 2 T1 and T2 repeated as day 1 Reas s es s ment: No further improvement to pain res pons e during s houlder elevation T1, T2 grade IV producing mild degree of local dis comfort 4 mins , prone, s houlder neutral Reas s es s ment: Shoulder elevation full range, 1 only with overpres s ure grade IV T1, T2 grade IV producing mild degree of local dis comfort 4 mins , prone, s houlder in end-of-range elevation Reas s es s ment: Shoulder elevation full range, pain free with overpres s ure GH IR in 90° exion (Hawkins –Kennedy) pain free
Day 8,Rx3 Fine from las t treatment with only minimal epis odes of or and able to complete 5-hour s hift at work largely pain free Noticed able to reach to cupboards much more comfortably , s till pres ent when reaching to extremes (functional demons tration of end-of-range elevation/abduction) T1, T2 grade IV producing mild degree of local dis comfort 4 mins , prone, s houlder in end-of-range elevation Reas s es s ment: Shoulder elevation full range, pain free with overpres s ure 2nd rib angle grade IV producing mild degree of local dis comfort 3 mins , prone, s houlder in end-ofrange elevation Reas s es s ment: Shoulder elevation full range, pain free, s houlder abduction full range pain free Quadrant mild , peak
235
C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
Cas e s tudy 4 5—cont’d es tablis hed No further contact was made by the patient during this time
Comments •
•
•
Fig ure 4.28 • Unilateral posteroanterior accessory mobilization T1 in cervical neutral in le t shoulder end-o -range elevation.
Day 22 No problems s ince las t treatment Able to complete full day’s work without pain undertaking all duties including lifting, carrying and reaching pain free Felt twinge on one epis ode lifting heavy s hopping bag into car Mrs M was s atis ed with the outcome at this s tage and did not feel that s he required any further treatment A two–month period during which the patient could return for further treatment s hould s ymptoms recur was
•
As advocated by Hengeveld and Banks (2005) ‘involvement of the cervicothoracic s pine intervertebral motion s egments s hould be cons idered in all dis orders of the s houlder Actual or potential movement impairment in thes e regions of the s pine can contribute mechanically to the ranges of movement available in the s houlder, as well as phys iologically to pain perceived in the s houlder but referred from the cervicothoracic s pine s tructures ’ This cas e s erves to highlight the importance of this contention, where acces s ory pas s ive mobilization treatment directed to the T1/T2 motion s egment and s econd rib led to res olution of s houlder pain and the as s ociated functional limitations in a 48-year-old lady An anatomical s tudy by Maigne et al (1991) provides a plaus ible rationale to explain this phenomenon by demons trating that the cutaneous medial branch of the dors al rami from the s econd thoracic nerve cours es laterally as far as the acromion Maigne et al (1991) des cribe the cours e of the thoracic dors al rami from their origin of the s pinal nerve pas s ing directly pos terior through a tunnel formed by the trans vers e proces s s uperiorly, the neck of the rib inferiorly, the facet joint medially and the s uperior cos totrans vers e ligament laterally Beyond this opening the nerve divides into medial and lateral branches , the cutaneous medial branch of the s econd dors al ramus which extends in a long loop innervating the s kin over the pos terior and lateral as pect of the s houlder Maitland et al (2005 p 304) notes the importance of knowledge of the cours e and s upply of the dors al rami es pecially at T2, T7 and T12 to the manipulative phys iotherapis t
Cas e s tudy 4 6 Dealing with a shoulder problem with multiple physical impairments and components Mrs P , a 53-ye a r-old p a rt-time c le a ne r Kind of dis order** Left s houlder pain and s tiffnes s es pecially when putting the left hand behind the back, ‘ bromyalgia’ and arthritis of the s pine and hips
Body chart features (Fig 4 29) Left anterior s houlder pain of a deep intermittent aching nature; occas ional s uper cial intermittent
236
tightnes s acros s the top of the left s capula At pres ent the low back is s tiff only in the mornings and the hips are s ymptom free , and s eem unrelated
Activity limitations /24-hour behaviour of s ymptoms Increas es with hand-behind-back movements ; the movement feels limited and painful and s ettles within ve minutes of s topping the movement
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Cas e s tudy 4 6—cont’d
Tight surface intermittent 2 1
4 Stiff deep intermittent
‘Ache’ deep intermittent
Stiff deep 3 intermittent
1 2 3 Separate
Fig ure 4.29 • Body chart o Mrs P.
Increas es with s tiffnes s when reaching above head height, becomes tired within ve minutes but goes off within one minute of s topping the movement Dis turbs s leep occas ionally when lying on the arm (once or twice per night) but goes off with s light adjus tment of pos ition Noticed at the end of the day or after a heavy s hift of cleaning, s till feels it when going to bed but has gone by the next morning Stiff in the morning when rolling out of bed and when bending forwards
Pres ent and pas t his tory Came on s pontaneous ly and gradually over the las t s ix months with a gradually noticeable limitation of activity and movement, no previous s ymptoms in this area Has had it on and off for the las t few years s ince increas ing her cleaning hours by 100% , occas ional s tiff neck in the pas t Has had it for 10 years or more but cannot recall having an injury, jus t lives with it, this has n’t been any wors e or better recently
Special ques tions Has been on prednis olone for as thma but not for s everal years Doctor told her s he has bromyalgia with her arthritis and thes e aches and pains are
helped by NSAIDs as and when required Als o s uffers from peripheral vas cular dis eas e, type 2 diabetes mellitus for the las t two years She has had an X-ray of her s houlder and it looks normal The rheumatologis t injected the s houlder once without any effects
Source/mechanis ms of s ymptom production More likely to be nociception, mainly from the glenohumeral, acromiohumeral or acromioclavicular complex, the cervicothoracic s pine and the lumbar intervertebral joints
The caus e of the s ource/contributing factors Look mainly for s tatic and dynamic alignment faults of the s pine as a caus e of the s ource of the s houlder impairment and the general ‘arthritic’ s tate
Obs ervation Left s houlder s loping more than the right, with the left s capula abducted relative to the right, los s of pos terior deltoid and s capula mus cle bulk, poking chin/head forward pos ition with dowager’s hump
Functional dem onstration/active m ovem ents •
Shoulder HBB (1) wris t to iliac cres t: • • •
+ glenohumeral MR (1)+ + AH compres s ion (1) ISQ + AC s queeze (1) ISQ
237
C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
Cas e s tudy 4 6—cont’d • • • •
Shoulder Ab 110° forward drift s tiff, correct drift + Shoulder exion 170° s tiff IV overpres s ure +, Shoulder H/Ad, Shoulder LR 40° ,
Other structures to test on D1 • • •
Lower cervical quadrant E1LLF1LR 10°, s tiff Cervical compres s ion, moderate Forward exion to mid-s hin s tiff + cervical exion ISQ Is o me tric te s ting – not tes ted on D1 Mus c le le ng th te s ting – not tes ted on D1 Ne uro lo g ic al e xaminatio n – not tes ted Ne uro dynamic s – not tes ted
the recovery of ideal s houlder movement, then mobilize s houlder medial rotation eventually clearing the quadrant and locking pos ition in conjunction with correction of pos tural alignment faults and mus cle imbalance correction Check neurodynamics later if neces s ary
D1,Rx1 On the s econd rib angle grade IV into a degree of for 3 mins
HBB quality better, range ISQ Shoulder Ab, F, LR ISQ Lower Cx Q/COMP FF ISQ
D5,Rx2 ISQ,
felt better les s ache EOD,
ISQ
Palpation •
•
Tendernes s on palpation of the anterior s houlder adjacent to the acromion proces s , but otherwis e no other s igni cant palpation ndings Thickening of s oft tis s ues and prominence at C7, T1, T2 inters pinous and over the articular pillars on the left
Passive m ovem ent • • • • • • •
•
Glenohumeral acces s ory movements in neutral ideal range and s ymptom free Glenohumeral and acromiohumeral joint compres s ion pain free Acromioclavicular or s ternoclavicular joint acces s ory movements ideal range and pain free Glenohumeral medial rotation in 90° abduction, 50° of movement limited by s tiffnes s and Shoulder quadrant low s ide and peak es pecially s tiff and , reproduced Quadrant appearance (Fig 4 30) Central and unilateral pos teroanterior acces s ory movement of C7, T1, T2, s tiff late range es pecially T2, local deep ache reproduced Unilateral pos teroanterior movement on the angle of rib 2, s tiff mid-range
Plan See how mobilization of the s tiff s econd rib affects the s houlder pain as a caus e of the s ource and a barrier to Degree of restriction
Fig ure 4.30 • Quadrant appearance (initial examination).
238
On the s econd rib angle grade IV+ into s tiffnes s and local pain, 3 mins In 90° s houlder Ab did caud grade III GH into a degree of for 2 mins
HBB ISQ Shoulder Ab, F, LR ISQ FF ISQ HBB range increas ed, wris t to L5 Shoulder Ab, F, LR ISQ FF ISQ
D7,Rx3 eas ier, gone, ISQ Main problem now is putting her coat on In 90° s houlder Ab did GH HBB, s houlder Ab, F, LR caud grades III/IV ISQ into a degree of , FF ISQ inters pers ed for 5 mins In 90° of s houlder Ab and HBB wris t to L2 les s s tiff 50° of medial rotation ISQ did of the head of Shoulder ABD, F, LR ISQ humerus grade for FF ISQ III+ into a 3 mins degree of
D12,Rx4 •
felt eas ier for a few days (putting coat on and lying on arm) but returned to normal level of pain after, neck felt s tiff after Rx4 and s till feels a bit s tiff • Shoulder movements ISQ, lower cervical extens ion s tiff 40° In prone did movement Cervical extens ion full range (55°) with grade III on T1, T2 into overpres s ure (IV) for 5 mins
In prone did movement grade III+ on T2 into for 4 mins
HBB wris t to T10 les s s tiff Shoulder Ab, F, LR ISQ FF ISQ Cervical extens ion HBB, Ab, F, LR ISQ
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Cas e s tudy 4 6—cont’d D30,Rx5 (away on holiday over Christm as) •
•
Shoulder feels loos er to move and eas ier to lie on but remains troubles ome with the s ame movements The neck and s houlder blade are now ne, the back is a bit s tiffer after all the s itting about over Chris tmas Cervical s pine , s houlder HBB wris t to T10 s tiff, s houlder lateral rotation is better 65° but Ab and F are ISQ, forward exion is s tiffer, hands to knees reproduces
In s upine lying did s houlder quadrant s cooping low s ide and peak grade IV− into a degree of for 4 mins
HBB better wris t to T7 s tiff Ab 150° s tiff , les s forward drift F 170° s tiff no ,
Figure 4 31 illus trates the quadrant appearance after Rx5
D33,Rx6 and subsequent treatm ents •
The s tretching of the quadrant had been followed up by a s eries of automobilizations for the s houlder into the quadrant pos ition (throughout the epis ode of care concurrent programmes of automobilization, functional s tability and mus cle balance were carried out)
Fig ure 4.31 • Quadrant appearance (a ter treatment f ve).
•
Starting to feel as though the treatment is being effective, the neck has been ne, the s houlder is feeling loos er and is les s noticeable In s upine did quadrant low s ide, locking pos ition and peak s cooping grade IV into dis comfort for ve minutes Further treatment did not res ult in any more improvement quickly The quadrant roll-over technique was us ed but was too painful and did not res ult in any further gain in range The patient was happy that her movements had returned and s he would continue to exercis e and us e the arm normally until s he felt there was no longer any res triction or until s he had forgotten about it
Cas e s tudy 4 7 Dealing with a shoulder problem with multiple physical impairments and components Mr H, 51-ye a r-old d e b t c olle c tor He does not partake in any s ports or hobbies He is right-handed
Kind of dis order **Right s houlder area pain with a pulling pain into the right s ide of the neck, es pecially when s at at work on the computer.
Body chart features (Fig 4 32) Right anterolateral s houlder pain of a cons tant/ variable deep dull aching nature (VAS 6/10); an intermittent daily s uper cial ‘bad toothache’ like pain on the anterolateral as pect of the neck (VAS 5/10) and s eem related He als o complained of achy knees which he felt were unrelated There is an old laminectomy s car in the lumbar area
Activity limitations /24-hour behaviour of s ymptoms ** and are aggravated by s itting for more than ve minutes and can be eas ed off by putting his right arm
up in the air ‘to eas e off the pres s ure’ within ve minutes and are als o aggravated by ve minutes of keyboard activity and can be eas ed off by getting up for a s troll around for les s than ve minutes On waking he is us ually s ymptom free but feels the s ymptoms are activity related during the day **In the evening the s ymptoms are aggravated when s at watching televis ion (to his right) His s leep is not dis turbed – he s leeps prone and nds it more comfortable with his head to the right *If he lies with his head turned to the left it pulls in his neck and lying s upine caus es a pulling feeling in the throat
Pres ent and pas t his tory Mr H feels the s ymptoms were related to an of ce move *Seven months prior to the examination he moved of ces and found he was s eated near a cold air ventilation s ys tem which blows acros s the top of his right s houlder A month later he ins idious ly developed This s lowly deteriorated and another month later he
239
C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
Cas e s tudy 4 7—cont’d Fig ure 4.32 • Body chart o Mr H.
2 Bad toothache-like, Intermittent, Superficial 5/10 1 Dull ache, constant, deep 6/10
3 Old laminectomy scar
1 2 Seem related
developed The s ymptoms were ISQ at the time of examination He had never had any previous neck or s houlder problems
was als o s itting with increas ed weight on his left buttock with a trunk s hift to the right, correction of which made no difference to his s ymptoms
Pas t medical his tory
*In s itting + right s houlder depres s ion + cervical lateral exion left increas ed moderate **Cervical rotation left 50° tight moderate + as s is ted elevation of right s houlder girdle increas ed cervical rotation left to 60° ‘s trong’ Cervical rotation left with right elbow extens ion and wris t extens ion decreas ed to 40° Cervical rotation right *Shoulder movements – exion
*Right leg s ymptoms ‘trapped nerve’ – had an operation 16 years ago and made a full recovery *Bas eball bat head injury s ix years ago
Special ques tions *Breathing dif culties , but not had any inves tigations No other medical problems *Current medication includes cocodamol and ibuprofen which help the s houlder area s ymptoms
Source/mechanis ms of s ymptom production Mos t likely to be chronic nociceptive pain with being from the acromioclavicular, acromiohumeral or glenohumeral joints and from the cervicothoracic s pine, rs t rib, s calenes or upper trapezius mus cle
The caus e of the s ource/contributing factors There could be a pos tural predis pos ition when s itting at the computer caus ing compromis ed tis s ue health and the ventilation s ys tem could be relevant His previous right-s ided leg s ymptoms could als o have predis pos ed the neural tis s ue to compromis e
Obs ervation Initial obs ervations were performed in s itting There was an increas ed thoracic kyphos is , correction of which did not change his s ymptoms *A hinge at C6 and a poking chin pos ture when corrected reduced s lightly He
240
Functional dem onstration/active m ovem ents
Other structures to test on D1 *ULNPT1 right −20° elbow extens ion , + cervical lateral exion right increas ed elbow extens ion to −10°
Isom etric testing/neurological exam ination Not tes ted on D1
Muscle length testing *Right upper trapezius mus cle tight mid-range
Palpation Generalized tendernes s was found around the s houlder complex but nothing s peci c
Plan Correct alignment faults and integrate, fundamentally to effect healthy movement in the cervical and thoracic s pine Check the rs t rib Check the thoracic s pine for impairments
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Cas e s tudy 4 7—cont’d D1,Rx1 Rx 1 – In s upine did s us tained IV+ 30 s econds × 4 cervical exion and lateral exion left s tretch to right upper trapezius mus cle Rx 2 – Repeated s ame treatment again Rx 3 – In s upine did unilateral AP C4 on the right s tiff and s ore mid-range, grade III and IV− × 2 mins , twice
• C/O decreas ed s lightly, P/E cervical rotation left ISQ, ULNPT1 increas ed range to -10° elbow extens ion, s houlder depres s ion + cervical lateral exion left mild All ISQ C/O decreas ed P/E cervical ration left increas ed to 65°, ULNPT1
D4,Rx2 •
C/O increas ed a m day after examination, ISQ during the day, pain moved further up along the trapezius mus cle Not s o much pain around the s houlder joint area and was OK lying prone with the head turned to the right in the night Aware of an ache in the cervical s pine area • P/E s itting weight bearing left greater than right (ISQ) Cervical rotation left ISQ Cervical rotation right ULNPT1 – 15° elbow extens ion Thoracic rotation left 30°, s tiff Thoracic rotation right 20°, s tiff++ Palpation T3/T4 prominent, ULPA on the right at T4 s tiff mid-range, ULPA T4 grade III s us tained produced a pain travelling around the ches t wall Reas s es s ment pos tpalpation: all ISQ Rx 1 – T4 rotation left C/O eas ier and right grade V P/E cervical rotation left 70° , ULPA T4 on the right s tiff late range Rx 2 – In s itting ULPA C/O ISQ C4 grade III with P/E cervical rotation left rotation left × 12 80° (pull), ULNPT1 ISQ Rx 3 – In s upine Did C/O ISQ ULAP on the right C4 P/E cervical rotation left grade III and IV × ISQ, ULNPT1 ISQ, ULAP 2 mins , twice C4 s ore mid-range, s tiff late range
•
P/E Obs ervations , decreas ed hinge at C6 Cervical rotation left 75° pull Cervical lateral exion left end of range pull Glenohumeral joint acces s ory mobilizations left = right Firs t rib acces s ory mobilizations left = right Right ULNPT1 -5° elbow extens ion
D12,Rx4 Rx1 – ULNPT1 tens ioner grade III with left cervical lateral exion × 3 mins C/O intermittent pull in rhythm Rx2 – cervical s ide glide to the left C4 grade III with right arm in ULNPT1 × 60 reps (Fig 4 33 as example of technique) Rx3 – T4 rotation left and right grade
C/O eas ier P/E ULNPT1 ISQ, cervical rotation left decreas ed pull and C/O freer P/E ULNPT1 grade IV+ pull, cervical rotation left 80° tight but painles s , cervical s ide exion left tight C/O les s tight P/E cervical rotation left 80° , right ULPA T4
C/O breathing again feels a little better No in the s houlder eas ier in neck area Als o eas ier at night
D8,Rx3 •
C/O Feels breathing has got eas ier up and down s tairs No in s houlder area Has felt aching in the right neck area Noticed anterior ches t pain in bed at night Neck s ymptoms s till wors e at work in the draught Patient hoping to s tart s wimming next week
Fig ure 4.33 • Cervical side glide to the le t C4 grade III with right arm in ULNPT1.
241
C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
Cas e s tudy 4 7—cont’d – s leeping OK Mild s ymptoms at work ‘Pleas ed with progres s ’ P/E minimal hinge at C6 Weight bearing more equally Cervical movements – rotation left 80° tight, s ide exion left end of range pull ULNPT1 grade IV+ pull (ISQ) Thoracic rotation left and right 40° s tiff ULPA T4 s tiff late range Rx1 – Cervical s ide exion left PPIVM III++ mid Cx C/O OK, P/E R in rhythm Rx2 – T4 rotation left grade V
As s es s ed s lump – no s igni cant differences left and right or with s ens itization
C/O eas ier movement P/E ULNPT1 ISQ, Cx Rot L 85° tight, SF L
C/O OK P/E Cx Rot L 85° , Tx Rot tight As s es s ed SLR – left = right 70° No indication for treatment ISQ
•
Rx3 – Home exercis es – reinforced pos ture/ alignment of s pine deep-breathing exercis es /Tx expans ion, maintain cervical rotation gains
Comments The theory of this gentleman’s pathobiological proces s es was long-term pos tural s tres s es leading to decreas ed tis s ue viability, which predis pos ed Mr H to nociceptive pain caus ed by the cold air ventilation s ys tem The SLR and s lump were as s es s ed in Rx4 becaus e of his previous s urgery and therefore potential neural tis s ue embarras s ment, Note the ‘double crus h’ phenomenon His condition was thought to be chronic, s table and non-irritable The patient’s aim was to reduce his pain This was achieved by addres s ing all the s igns in the cervical s pine, thoracic s pine and in the ULNPT1 Although Mr H’s main pain was located in the region of the s houlder complex, his main functional impairment was related to s itting at work and us ing the mous e Clues to there being other components to the problem were his problem with s leeping prone with his head turned to the left (cervical) and his breathing dif culties (thoracic)
Cas e s tudy 4 8 Dealing with a shoulder problem with multiple physical impairments and components Mrs G, a 53-ye a r-old la d y, re fe rre d to p hys iothe ra p y from a n orthop a e d ic CATS c linic b y a n ESP Pres ent and pas t his tory Mrs G reported an ins idious ons et of left s houlder pain around one year prior to her initial as s es s ment in phys iotherapy She had been troubled with intermittent pain in the left s ide of her neck for the las t ve years but had it had not troubled her s uf ciently for her to s eek help Over the preceding three months s he then developed an ins idious ons et of intermittent pins and needles and numbnes s in the left arm ( , ) (Fig 4 34) The concern over the pins and needles and numbnes s combined with the trouble that her left s houlder caus ed her day to day were the factors that took her to her GP, where a referral to an orthopaedic CATS was made Cons equently, a referral to phys iotherapy was made by the ESP in CATS Mrs G worked as a legal s ecretary having done s o for more than 20 years She reported that her workload
242
continues to increas e year on year Her main hobby was attending a gym typically three or four times per week, which s he had done for the pas t few years Although initially her training was unaffected des pite the pres ence of over the las t s ix months s he found upper limb weights increas ingly dif cult due to and had s topped thes e activities over the las t three months when s he developed and
Activity limitations /24-hour behaviour of s ymptoms The primary functional problem reported was dif culty lifting her bag from the pas s enger s eat of her car due to was als o reported at work when lifting ling work into ling drawers and als o when dres s ing and putting her arm into s hirts , jackets and jumpers was pres ent whils t us ing the computer wors ening with increas ed duration forcing her to s top and change pos ition after one hour had a tendency to wors en as the day progres s ed and had no identi able pattern that Mrs G was able to recognize
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Cas e s tudy 4 8—cont’d Fig ure 4.34 • Body chart o Mrs G.
2 Ache, intermittent, deep 1 Sharp, intermittent, deep 3 Pins and needles intermittent 4 Numbness intermittent
1 2 3 4 Separate
Examination Initial examination revealed multiple phys ical impairments Mos t notably: •
•
• •
•
• •
The functional demons tration of active abduction (to s imulate lifting bag from pas s enger s eat of car) increas ed An increas e in was produced with acromiohumeral compres s ion in this pos ition and with is ometric abduction and lateral rotation mus cle contraction No effect on was produced with alterations to cervical pos itions or pos ture or with modi ed neurodynamic tes ting in this pos ition Cervical left rotation was res tricted to 60° with an increas e in at end of range- s us taining this pos ition for 10 s econds produced and Cervical left s ide exion was res tricted to 40° and extens ion to a moderate degree both of which produced the s ame s ymptoms res pons e as left rotation including the res pons e to s us tained pos itioning Cervical right rotation, right s ide exion and exion were full and pain free Acces s ory motion tes ting of the cervical s pine revealed s tiffnes s in the motion s egments C4-7 on the left with comparable provocation of on unilateral pos teroanterior mobilization in the region of the left C5/C6 and C6/C7 facet joints Acces s ory motion of the rs t and s econd ribs with a variety of directions revealed range of movement comparable to the unaffected right s ide and no s ymptom provocation Neurological tes ting revealed no evidence of compromis e to conduction Neurodynamic tes ting revealed a pos itive res pons e to ULNPT 2a producing (des ens itized moving the
•
wris t from extens ion to neutral) and (des ens itized moving the s houlder from abduction 30° back to the patient’s s ide) The left s houlder revealed full range to elevation and abduction with an arc through both movements and again s light increas e at limit of range Pas s ively the left s houlder revealed full range to elevation and abduction with mild increas e at the limit of range
Ses s ions 1–3 Treatment was aimed at addres s ing the impairments in the cervical s pine to phys iological and acces s ory movement Pas s ive acces s ory unilateral pos teroanterior mobilization on the left C4-7 motion s egments initially in neutral then progres s ing to a s tarting pos ition of left rotation produced res toration of full pain-free active cervical left rotation and left s ide exion By the end of s es s ion 3 a concurrent res olution of and ) had als o been produced pers is ted to a mild degree only at the end of a working day, but to a s atis factory level as deemed by the patient Active cervical range of movement exercis e was pres cribed at the end of each treatment s es s ion to maintain the improvements in range gained in treatment Advice regarding pos ture and encouragement of regular changes to pos ition through a working day was encouraged Mrs G was encouraged to avoid lifting her bag from the pas s enger s eat of her car to prevent provocation of Reas s es s ment of s houlder range of movement and res pons e of remain unchanged at the end of s es s ion 3 The previous ly impaired ULNPT 2a and later as s es s ed ULNPT 1 res olved without the need for neurodynamic mobilization
243
C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
Cas e s tudy 4 8—cont’d Ses s ions 4 and 5 The problems related to pers is ted at this s tage including provocation during dres s ing (putting on jumpers , s hirts and coats ), lifting les into and out of ling cabinets at work Mrs G had not returned to upper limb exercis e at the gym at this s tage due to the pers is tence of Cons is tent with the initial as s es s ment a painful arc (increas e ) through elevation and abduction was pres ent with an increas e in at the limit of range of elevation and abduction Differential tes ting continued to reveal an increas e in with acromiohumeral compres s ion indicating a pos s ible s ubacromial s ource to the s ymptom was produced with is ometric contraction of both abduction and lateral rotation no matter the s tarting pos ition of the left s houlder although a more intens e provocation was pres ent when the s houlder was in 90° abduction In this pos ition, acromiohumeral dis traction (longitudinal caudad humerus ) did not relieve or improve the pain res pons e with Longitudinal caudad mobilization of the humerus in a variety of s tarting pos itions failed to improve during active abduction Mobilization into the res tricted quadrant pos ition was not tolerated well As s es s ment of a number of other pos s ible impairments that have been as s ociated with extrins ic s ources of s ubacromial impingement was undertaken Thes e factors have been dis cus s ed in previous s ections of this chapter and are s ummarized in Tables 4 3 and 4 4 In particular, motor control as s es s ment revealed s atis factory s capula s tability and dynamic control Indeed, s capulothoracic movement facilitation failed to affect the pres ence of Glenohumeral medial rotation range of movement was unimpaired in comparis on to the unaffected right s ide Thoracic mobility was addres s ed with mobilization remained unchanged
Ses s ion 6 and onwards The impairment to res is ted contraction during both abduction and lateral rotation pers is ted and a hypothes is of a tens ile les ion of the s capulohumeral mus cles was cons equently es tablis hed Extrins ic compres s ive impingement s econdary to poor humeral head control was als o cons idered a pos s ibility s econdary to poor rotator cuff function Cons equently, a graded loading programme of exercis e was pres cribed with an emphas is on maintaining good glenohumeral movement control Initially progres s ive is ometric contractions of both lateral rotation and abduction were undertaken with the arm by the s ide with a s trength of contraction ins uf cient to produce Attention was paid to the s tarting pos ition of the s houlder complex to provide an optimal alignment and prevention of compens atory s trategies , that is , los s of s tarting pos ition, s houlder
244
s hrugging, los s of s capula control etc Over a one-week period of repetitive exercis e s trong, painles s is ometric contractions were gained Treatment progres s ed to is ometric contraction through range particularly towards the provocative pos ition of 90° abduction again with the avoidance of By the end of the third week of training s trong painles s is ometric contractions were achievable of both abduction and lateral rotation in a variety of s tarting s houlder pos itions Mrs G reported that the intens ity and frequency of had improved by 80% The previous ly res tricted s houlder quadrant, at this s tage was reas s es s ed and felt to be largely comparable to the unaffected right s ide and the pain previous ly pres ent at the end of s houlder elevation had als o res olved Treatment progres s ed to s low, is otonic concentric contractions of lateral rotation (with external res is tance provided by theraband) again initially with the arm by the s ide moving quickly into the provocative pos ition of 90° abduction Again the s trength of contraction and range of movement produced was undertaken in a pain-free manner Strength, range and change of s houlder s tarting pos ition was only undertaken as s ymptoms allowed At review s ix weeks following commencement of the exercis e loading programme Mrs G was as ymptomatic with regard to with daily activities She was able to demons trate through range lateral rotation concentric control with res is tance She expres s ed being keen to return to the upper limb gym work s he had previous ly undertaken prior to her s houlder, neck and arm problem Rehabilitation was progres s ed to a higher level with changes of s peed, types of contractions and s tarting pos itions of s houlder elevation and abduction At a three-month review Mrs G had returned to her upper limb gym rehabilitation program without s ymptoms Previous training errors were addres s ed, that is , cons ecutive days training changed to alternate days , etc She was dis charged at this s tage and as ked to contact the department s hould s he experience any recurrence over the following three-month period No contact was made
Comments Phys iotherapy management of s houlder dis orders is often multimodal in nature, with pas s ive movement forming one component of intervention This cas e aims to demons trate the integration and role of pas s ive mobilization in a patient pres enting with a multicomponent neck, s houlder and arm dis order in the wider context of their overall management The cas e als o s erves to demons trate where hypothes es regarding the pathobiology (mechanis ms related to the tis s ues ) combined with advancing knowledge regarding the pathology (in this cas e tendinopathy) (the left s ide of the permeable brick wall)
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Cas e s tudy 4 8—cont’d may be integrated with the clinical evidence (the right s ide of the permeable brick wall) from the patient as s es s ment to inform phys iotherapy management decis ions As s tated by Maitland (2005), ‘the decis ion making proces s of the Maitland Concept is primarily on the clinical evidence s ide of the brick wall although diagnos tic and theoretical cons iderations will in uence the exact nature and dos age of the intervention’ In this particular cas e a pers is tent impairment to res is ted abduction and lateral rotation was reas oned to be the phys ical impairment mos t clos ely related to the functional limitations of the patient following the res olution of others with phys iotherapy treatment Integrating s cienti c evidence relating to rotator cuff pathology s uch as detailed in Tables 4 3 and 4 4 allowed a hypothes is to be generated regarding rotator cuff tendinopathy as a possible explanation for the clinical pres entation at this s tage (theory) Current evidence has demons trated that mechanical loading of tendon tis s ue can promote cellular level s tructural change to promote tendon healing and repair via the concept of mechanotrans duction (Khan & Scott 2009) The cas e for s uch an approach in rotator cuff tendinopathy at this s tage of s cienti c unders tanding is continuing to build given that the pathological features of the condition appear related to either a failed healing res pons e or as a degenerative proces s as has been dis cus s ed in more detail in the s ection covering a clinical example relating to rotator cuff tendinopathy on pages 164–168 (Cook & Purdam 2009) Des pite the dif culties that have been as s ociated with the interpretation of res earch relating to the phys iotherapy
treatment of ‘impingement s yndrome’ which have been thoroughly dis cus s ed in other s ections of this chapter and Table 4 9, exercis e combined with manual therapy has been s hown to be an effective treatment for this clinical pres entation in four recent s ys tematic reviews (Kelly et al 2010, Braun & Hanchard 2010, Kromer et al 2009, Kuhn 2009) Obvious ly when cons idering the lack of diagnos tic accuracy that s pecial phys ical orthopaedic tes ts pos s es s in identifying s tructural pathologies in the s houlder (as dis cus s ed earlier in the chapter) it was not pos s ible to s ugges t with any certainty that this was indeed the pathological les ion in this particular cas e Furthermore, even if imaging evidence had been made available the management decis ions would not have changed given the high prevalence of rotator cuff pathology in as ymptomatic individuals Nonetheles s , addres s ing the impaired contractile component of the s houlder problem hypothes ized as a rotator cuff tendinopathy warranted tes ting s upported by ‘clinical proof of whether treatment is working or not is achieved by continually comparing the effects of the s elected treatment forms on the patient’s s ymptoms and s igns ’ Maitland (2005) ‘At the s ame time, hypothes es about the caus e of the problem, the s tructures at fault, the pathobiological mechanis ms involved, expectations for recovery and appropriate management s trategies can be con rmed dis carded or re-ranked ”(Maitland et al 2005) In this particular cas e the clinical outcome was favourable s upporting the contention of the link between the contractile impairment with the patient’s functional limitations
Cas e s tudy 4 9 Dealing with the pain ul shoulder Mr G, a 79-year-old gentleman was referred to phys iotherapy by a cons ultant orthopaedic s urgeon with a medical diagnos is of right s houlder s ubacromial impingement
Kind of dis order Right s houlder pain and as s ociated painfully limited range of movement.
Pres ent and pas t his tory Mr G had s uffered a fall onto an outs tretched hand s even months prior to his attendance in phys iotherapy He s uffered an immediate ons et of pain in the region of his right s houlder and opted initially to s elf manage his problem Mr G recalled pain in the region of and
following the fall and were reported to have become noticeable over the three months preceding his phys iotherapy initial as s es s ment (Fig 4 35) Unfortunately, his s ymptoms pers is ted and he cons equently s ought help from his GP who chos e to inves tigate the problem with X-ray and ultras ound s can, the res ults of which are detailed below Bas ed upon the res ults the GP referred the patient directly to a cons ultant orthopaedic s houlder s urgeon for opinion without acces s ing an orthopaedic CATS The patient was as s es s ed by the cons ultant who referred the patient for phys iotherapy Prior to the fall Mr G had experienced no previous problems with his right s houlder He regularly attended a gym and played golf but had been unable to do s ince
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C H AP TE R 4
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
Cas e s tudy 4 9—cont’d
1 Dull ache, constant, deep
3 Stiff, Intermittent, deep
2 Sharp, shooting Intermittent, deep
2 4 Ache,pulling, intermittent, deep
Typically
1
2
3
4 Separate
Fig ure 4.35 • Body chart o Mr G.
the time of the fall His main aim in phys iotherapy was to be able to return to thes e activities
Activity limitations /24-hour behaviour of s ymptoms The principal functional limitation was elevation of right arm due to s everity of and which increas ed rapidly nearing the end of the available range of movement, taking a couple of minutes to s ettle when placing the arm back by the s ide Cons equently, problems with dres s ing and reaching activities were reported Sleep was dis turbed mos t nights due to , and , when lying in the right s ide, s ettling within ve minutes when changing pos ition Mr G was able to note an increas e in particularly when trying to place his right hand behind his back and when s itting for more than 30 minutes
Medical imaging inves tigation Ultrasound right shoulder Moderate mechanical changes in the AC joint with caps ular thickening Biceps tendon appears intact with a normal s ubs capularis The s upras pinatus is s lightly thickened with s ome heterogeneity of architecture compatible with tendinos is There is thickening of the s ubacromial s ubdeltoid burs a and on elevation there is clear evidence of impingement with effus ion in the s ubacromial s ubdeltoid burs a (SASD) The infras pinatus is normal with no evidence of rotator cuff tear Comment: Impingement changes right s upras pinatus tendon with SASD burs itis Burs al effus ion No rotator cuff tear
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X-ray o right shoulder There is s ome calci cation in the s oft tis s ues at the acromioclavicular joint s ugges ting ps eudo gout The glenohumeral joint has a normal appearance There is no fracture or dis location Interpretation- imaging res ults allowed information regarding the s tate of the tis s ues in the s houlder complex to be acknowledged and provide evidence for the left s ide of the brick wall Points of particular interes t noted were degenerative changes to the acromioclavicular joint, evidence of s ubacromial impingement and burs al effus ion, s upras pinatus tendinos is and a normal glenohumeral joint This knowledge was tempered with cons ideration that prior to the fall Mr G had experienced no previous s ymptoms in his right s houlder Note: readers are directed to us e information from Tables 4 8 and 4 9 to review the cons iderations relating to thes e medical ndings
Examination Initial examination was limited due to the s everity of s ymptoms The primary impairments identi ed initially were painful res trictions to right s houlder active range of movement to elevation 80° (1) (2), abduction 60° (1) (2) and lateral rotation 40° (1) (2) Pas s ively around 10° further range was achievable with care but again pain limited at this s tage (1) (2) Cervical s pine range of movement revealed res triction at 50° rotation in both directions due to s tiffnes s with an increas e of at the limit of available range
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Cas e s tudy 4 9—cont’d Acces s ory motion tes ting revealed painful res triction of the s houlder to both anteropos terior and pos teroanterior directions Acces s ory motion tes ting of the cervical s pine revealed s tiffnes s from the mid to lower regions with provocation of on unilateral pos terioanterior mobilization of the right C5, C6 and C7 facet joints A modi ed neural tis s ue provocation tes t (2a) did not in uence the s ymptoms , , or A peripheral nociceptive pain dominant pres entation with s ources from the glenohumeral/? acromiohumeral/ cervical s pine and ? acromioclavicular complexes was felt to be the mos t likely mechanis m at this s tage
Rx1 At this early s tage s everal impairments had been identi ed including painful res triction to both phys iological and acces s ory movement of the s houlder complex and impairments of the cervical s pine to phys iological and acces s ory motion due to s tiffnes s As s uch, s everal options for treatment exis ted A clinical judgement was made to commence treatment directed to the painfully res tricted ranges of movement at the s houlder complex The patient was pos itioned in an antalgic pos ition of s upine with two pillows under the upper right arm s upporting it by the patient’s s ide Acces s ory movements of the humerus were applied initially in a pos teroanterior direction and longitudinal caudad direction us ing pain modulating grade I and II techniques applied in a s low and gentle manner avoiding the provocation of pain (Fig 4 36) Within a few minutes the amplitude of the movement was able to be increas ed and the patient reported a reduction in their res ting level of pain The patient appeared more relaxed to movement of his s houlder and pas s ive phys iological exion was able
Fig ure 4.36 • Posteroanterior accessory mobilization right humeral head with the arm supported in the most com ortable position.
to be applied again in a s low, s upported and gentle manner highly res pectful and avoidant of provoking the patient’s s houlder pain Within the treatment s es s ion pas s ive movement of the s houlder had improved from 80° up to approximately 150° The patient was taught pendular exercis e in an attempt to maintain the improvements in the pas s ive range of movement of the s houlder The patient s tated that he was reas s ured that he s hould begin to move his s houlder again as to date he had largely avoided movement and activity due to fear of caus ing more harm and pain
Rx2 and Rx3 The pas s ive movements applied during s es s ion 1 were repeated in s es s ions 2 and 3 Impairments to s capulothoracic elevation, depres s ion, protraction and retraction were addres s ed through pas s ive mobilization Active as s is ted range of movement of the s houlder was commenced in a s upine pos ition By the end of s es s ion 3 160° active elevation of the s houlder was achievable in s upine and in s tanding 140° was reached, both being limited by pain and The patient progres s ed to active range of movement to elevation of the s houlder both lying and in s tanding with the elbow exed (s hort lever) He reported gaining con dence again with movements of his s houlder and arm
Rx4 and Rx5 The impairments in the cervical s pine noted at initial as s es s ment were addres s ed with acces s ory unilateral mobilization which led to improvements to both cervical range and s houlder range of movement By the end of s es s ion 4, active s houlder elevation and abduction range of movement had improved to 170° limited by alone Mr G reported res olution of and with only intermittent on s tretching for example when putting his jumper over his head On further examination of pas s ive elevation was identi ed at the limit of range along with The s houlder quadrant was impaired on as s es s ment with provocation of and Differentiation procedures identi ed pos s ible s ource to both at the acromioclavicular joint and acromiohumeral joint A clear differentiation between thes e two s ources was not pos s ible Examination of the upper thoracic s pine with unilateral pos teroanterior mobilization of the right T1 and T2 revealed impairment with local pain and s tiffnes s A hypothes is of a pos s ible s ymptom s ource of and contributing factor to was generated and tes ted with s trong acces s ory mobilization techniques applied to addres s the s egmental s tiffnes s On reas s es s ment the range of s houlder movement was unaffected although was not reproducible during the quadrant or at the limit of elevation as it had been
Rx6 Impairment to acces s ory motion of the right acromioclavicular joint was felt important as a pos s ible remaining s ource to and reas on for the impairment to
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Cas e s tudy 4 9—cont’d full s houlder elevation and abduction, which was limited actively at 170° and pas s ively in the las t few degrees In end-of-range elevation acces s ory movement of the acromioclavicular joint was applied in both an anteropos terior and longitudinal caudad direction us ing initially pain relieving grade II techniques progres s ing to s tronger grade IV techniques as able Reas s es s ment revealed full pas s ive and active range to s houlder elevation and abduction, however pers is ted at the limit of range The s houlder quadrant als o continued to reveal mild res triction with provocation of Two further applications of mobilization in a s imilar manner to the acromioclavicular joint failed to improve matters any further Differentiation tes ting was again applied in this end of range which continued to s ugges t an acromiohumeral s ource with a reduction in when a longitudinal caudad acces s ory movement was applied to the humerus (s ubacromial dis traction) (Fig 4 37) At this s tage, the irritability and s everity of the problem was judged to be low and gentle us e of the impaired quadrant as a mobilization technique was applied This technique provided further improvement s uch that the patient reported full pain-free range of movement to s houlder elevation and abduction with s trong overpres s ure
Rx7 Mr G reported feeling extremely happy with his s houlder He was able to undertake mos t tas ks on a daily bas is that us ed the right s houlder and arm without pain or dif culty He reported only a very occas ional twinge 1 when putting the arm into ‘awkward’ pos itions
Fig ure 4.37 • Longitudinal caudad accessory mobilizations to the ACJ in elevation.
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and occas ionally when lying on the right s houlder Mild res triction to the right s houlder quadrant pers is ted; otherwis e s houlder movement was full and pain free A judgement was made to s top treatment at this s tage and monitor the s ymptoms over a period of one month Mr G demons trated a golf s wing within s es s ion which was pain free and was advis ed to make a graded return to this activity
Rx8 – one-m onth review At this s tage Mr G remained happy and s atis ed with his outcome He had returned to golf and was now playing at his preinjury level He felt that no further treatment was required at this s tage and was cons equently dis charged from phys iotherapy No contact was made over the following two-month period indicating no recurrence of problems to an extent which required input as was agreed
Comments This cas e s erves to highlight the importance phys iotherapis ts s hould pay to identifying all pos s ible s ources and contributing factors in any individual clinical pres entation Although a s peci c medical diagnos is s upported by the us e of imaging which demons trated s everal pathological tis s ues was pres ent in this cas e, many other s ources and contributing factors were identi ed us ing an impairment-bas ed approach which when addres s ed contributed (evidenced by reas s es s ment of effect) to res olution of the patient’s problems This cas e s upports the contention that phys iotherapis ts mus t pos s es s ‘an open minded attitude to treatment techniques being able to innovate freely, unhindered by theory’ s upported by meticulous reas s es s ment (Maitland 1986) The s peci c limitations as s ociated with the medical diagnos is of ‘s ubacromial impingement’ have been thoroughly dis cus s ed in preceding s ections in this chapter Maitland’s recognitions of the dif culties , limitations and obs tructions to patient management s hould phys iotherapy treatment be directed by the medical diagnos is alone are particularly pertinent to this diagnos is (Maitland 1986) The cas e als o demons trates the utility of us ing gentle, controlled pas s ive mobilization in a patient with a pain dominant pres entation Such an approach is cons idered by Maitland (1986) as of particular importance for the Maitland Concept, which demands therapis ts develop ‘a clear unders tanding of how to treat pain by us ing os cillatory techniques which are totally painles s and do not include any s tretching whats oever’
S h o u ld e r c o n d itio n s – a p h ys io th e ra p y p e rs p e c tive
Cas e s tudy 4 10 Dealing with a sti shoulder Mr C, a 57-ye a r-old p owe r s ta tion worke r
Treatment
His tory
Due to the ndings s o far the pas s ive acces s ory movement examination was concentrated on the glenohumeral joint This was found to have s tiffnes s in the mid-range in all directions As a res ult, treatment cons is ted of mobilizations of the glenohumeral joint into the s tiffnes s (grade IV−) Glenohumeral pos teroanterior, anteropos terior and longitudinal caudad mobilizations were performed (Fig 4 39) The arm was initially pos itioned in neutral but becaus e there was no aggravation of the s ymptoms after reas s es s ment and becaus e his problem was s tiffnes s dominant and not irritable, the s ame techniques were performed in end-range abduction and then in exion and then in lateral rotation The immediate effect was an increas e in his active range of exion and abduction with les s intens e pain Interes tingly his hand-behind-back movement als o improved
Mr C was a 57-year-old power s tation worker referred to phys iotherapy with a four-month his tory of a painful and s tiff right s houlder The problem began ins idious ly in the abs ence of any trauma and was in s tatus quo at the time of examination The pain was des cribed as intermittent on the anterior and lateral as pect of the right glenohumeral joint area (Fig 4 38) It was aggravated by reaching into forward elevation and by applying pres s ure agains t a wall in elevation s uch as when us ing a s crewdriver At night he was unable to lie on the right s ide due to aggravation of the pain His general health was unremarkable and he was not currently taking any medication His work at the power s tation involved heavy work, climbing and ne tool work He was right-handed
Examination On examination his pain was pres ent prior to any movement His functional demons tration was active exion which was further s ymptomatic and s tiff at 120° Differentiation in this pos ition highlighted his glenohumeral joint to be the mos t affected component His pain was als o increas ed with abduction at 90°, lateral rotation was s tiff at 20° and hand-behind-back movement (medial rotation, extens ion and adduction) was painful with hand to buttock Further differentiation of this movement found the medial rotation component to be the mos t affected This pattern of res triction is commonly referred to as a caps ular pattern, as termed by Cyriax (1978) Res is ted movements were generally uncomfortable with no s peci c ndings The addition of acromiohumeral dis traction prior to performing the res is ted movements did not change the s ymptom res pons e
Outcome The above mobilizations were progres s ed to grade IV+’s as the s ymptom res pons e allowed and combined with end-of-range phys iological techniques Pos teroanterior pres s ure to the inferior angle of the right s capula in prone with the hand behind the back was als o found to be effective at further improving the hand-behind-back function After ve s es s ions of treatment Mr C was dis charged with a return to full function in elevation and hand-behind-back movements
Comments This cas e s tudy s erves to highlight the importance of as s es s ing the joint s igns and treating them appropriately When s tiffnes s in the glenohumeral joint acces s ory movements was addres s ed the patient’s function was improved This patient als o highlights that a caps ular pattern of res triction may not always mean a ‘frozen s houlder’ which is often unres pons ive to phys iotherapy treatment
Fig ure 4.38 • Body chart o Mr C.
1 Intermittent, ache progresses to sharp
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Cas e s tudy 4 10—cont’d
Fig ure 4.40 • Posteroanterior mobilizations applied to the in erior angle o the scapula in the hand-behindback position.
Fig ure 4.39 • Glenohumeral posteroanterior mobilizations o the humeral head with the arm in 120° abduction whilst maintaining ull external rotation.
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C H AP TE R C O N TE N TS Introd uc tion
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Evid e nc e -b a s e d p ra c tic e with re fe re nc e to ma nua l the ra p y
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P hys ic a l e xa mina tion: the e lb ow c omp le x
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Exa mina tion a nd tre a tme nt te c hniq ue s
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Elb ow d is ord e rs a nd the ir c linic a l p ro le s
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Key words Superior radioulnar joint, humeroulnar joint, radiohumeral joint, radial nerve, ulnar nerve, median nerve, extens or carpi radialis brevis , common extens or origin, common f exor origin
Intro duc tio n Potential sources o pain in the elbow region are diverse, ranging rom the joints, bone, muscles, nerves, ascia, bursae and other so t tissues. H ence, evaluation o a person presenting with pain in the elbow region requires a comprehensive exami nation procedure encompassing all potential pain sources. The intention o this chapter is to provide an integrated approach incorporating the articular, neural and muscle systems. Comprehensive manual
examination procedures will be presented with clinical reasoning processes to enable the clinician to identi y with as much clarity the source o elbow pain. Consequently, the astute, prof cient clinician will be able to treat and manage a wide range o pain disorders a ecting the elbow region. It cannot be overstated that elbow symptoms may arise rom local structures such as the humero ulnar joint, as well as remote structures such as the cervical and thoracic spine. The potential or spine involvement in elbow pain has long been reported (Berglund et al. 2008, DeFranca & Levine 1995, H aker 1993, Noteboom et al. 1994, Yung et al. 2011). Failure to address remote structure involve ment is likely to reduce treatment e ectiveness or prolong therapy. There is some evidence to indicate that manual therapy applied to remote structures can in uence elbow symptoms. For example, in sub jects with lateral epicondylalgia, Vicenzino et al. (1996) demonstrated that a cervical lateral glide technique, when compared to a control and placebo condition, had immediate positive e ects on pain, pain ree grip strength, elbow pressure pain thresh olds, and the neurodynamics o the upper limb. Furthermore, it has been shown that or lateral epi condylalgia, local elbow management together with treatment directed at the spine achieved a success ul long term outcome in signif cantly ewer visits than local elbow management alone (Cleland et al. 2004). Di f culty arises when trying to identi y rom where pain may originate (Curatolo et al. 2006). For example, people who su er with chronic lateral epicondylalgia demonstrate widespread areas o 261
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proximal and distal re erred pain (Slater et al. 2005), a hallmark eature o central sensitization. The presence o central sensitization distorts the clinical picture, making a def nitive diagnosis di f cult (Curatolo et al. 2006). In addition, there may be re erred pain rom proximal structures, particu larly the spine. Berglund et al. (2008) compared a cohort o actory workers with and without lateral epicondylalgia. They reported a much higher re quency o cervical and thoracic spine pain (70%) in subjects with elbow pain than those without (16%). They also ound a much higher incidence o positive f ndings to upper limb neurodynamic testing and pain provocation tests o the spine in subjects with elbow pain. The presence o spine pain together with pain in the elbow region does not def nitively indicate the cause o the elbow symptoms will be the proximal structures. H owever, this evidence indicates the importance o care ul subjective and physical examination in patients presenting with elbow pain. Particular care should be given to iden ti ying symptoms throughout the upper limb, as well as the spine. Patients with elbow pain will o ten have more than one pain. O n care ul questioning, it may be possible to identi y a di erence or each pain with respect to movement related behaviour. Con sequently, each pain may have di erent origins and may need treating in di erent ways.
Anatomical and biomechanical cons iderations The elbow region is a complex o articulations, which comprises the humeroular joint, radiohumeral joint and proximal radioulnar joint. While the proxi mal radioulnar joint is not strictly involved in the elbow motion o exion and extension, it is included in this chapter because o its anatomical position and proximity to the radiohumeral joint. The superior radioulnar joint is concerned prima rily with the movement o pronation and supination. The articular sur aces include the convex, cylindrical shaped rim o the radial head and the reciprocally shaped osseof brous concavity created by the radial notch o the ulna and the annular ligament. Normal range (age 20–44) or pronation is reported as 82° or emales and 77° or males; supination is 91° or emales and 85° or males respectively (Soucie et al. 2010). Pronation range increases in extension, and vice versa or supination (Shaaban et al. 2008). Range is also inversely related to age. 262
The humeroulnar joint is a uniaxial hinge joint ormed between the trochlear notch o the ulna and the trochlea o the humerus. The joint sur aces are saddle shaped, being concave in the sagittal plane, and convex in the rontal plane (Standring 2008). The axis o movement or exion and exten sion is asymmetrical, which accounts or the carrying angle in the terminal range o extension with the orearm supinated. The carrying angle in this posi tion is 17°, with no signif cant di erence between men and women according to a recent large scale survey (Kumar et al. 2010). Consideration o the carrying angle is important, particularly when mobi lizing the elbow in the end range o extension and supination. The primary active movements available at the humeroulnar joint are exion and extension with a small range o pronation and supination. For people aged 20 to 44, normal range or exion in emales is 150° and in males 145°; extension is 5° or emales and 1° or males (Soucie et al. 2010). The asymmetry and saddle shaped nature o the humeroulnar joint sur aces allow small range o internal and external rotation around the long axis o the ulna (Lockard, 2006). H ence, rotation o the ulna can contribute towards orearm pronation and supination. Coupled internal and external rotation o the ulnar also occurs during exion and extension (Armstrong et al. 2000): external rotation during exion in supination; internal rotation during exion in pronation (Bryce & Armstrong 2008). Altered ulnar rotation may account or pain and/ or limitation o elbow extension (particularly in chronic and recurrent elbow pain disorders, such as throwing injuries). Altered rotation may alter the trochlea articular contact area during move ment. In this way, the olecranon moving on the humerus can be likened to the patella moving on the emur. Just as altered patello emoral dynamics is a commonly postulated cause o anterior knee pain, so altered dynamics o ulnar rotation may also be a common cause o pain and movement limitation at the elbow. In the Mulligan Concept (Mulligan 2010), subtly altering ulnar rotation through mobilization with movement (MWM) can be a potent treatment option to manage some elbow movement disorders. The radiohumeral articulation is a triaxial ball and socket joint, which lies between the convex shaped capitulum o the humerus and the concave shaped radial head. Movements occurring at this joint are exion and extension as well as pronation and
S u b je c tive e xa m in a tio n
supination. The axis o pronation and supination lies approximately about a line drawn rom the centre o the humeral head to the distal head o the ulnar (Bryce & Armstrong 2008). This joint may be dys unctional in movement related joint disorders inducing pain in the lateral elbow. Although the elbow is not typically considered a weight bearing joint, there are signif cant compres sive and shear orces at the elbow during certain movements. For example, per orming a simple press up induces a compression orce o 45% o body weight across the elbow joint (An et al. 1992). G reater orce is transmitted through the radio humeral joint, with only 43% borne by the ulna (Bryce & Armstrong 2008). H ence, weight bearing unction may need to be considered in some patients with elbow pain. Various nerve trunks pass across the elbow joint, and may be susceptible to abnormal compression loading, or repetitive micro trauma invoking in am matory change, at a number o vulnerable sites (H ariri & McAdams 2010). For example, the poste rior interosseous nerve is a branch o the radial nerve, which is vulnerable to stress in the radial tunnel, but is most commonly a ected as it passes through the tendinous arcade o Frohse on the prox imal edge o the supinator muscle (Clavert et al. 2009). The ulnar nerve may be compressed, in amed or irritated in the cubital tunnel. The ulnar collateral ligament, the medial edge o the trochlea, and the medial epicondylar groove orm the boundaries o the cubital tunnel, with the roo ormed by the arcuate ligament complex. A urther our sites o ulna nerve compression have been reported in the elbow region (H ariri & McAdams 2010). The median nerve may be compressed at our sites (H ariri & McAdams 2010): the ligament o Struthers (originates at the supracondylar process and inserts on the medial epicondyle), the bicipital aponeurosis, the pronator teres muscle, and the proximal arch o the exor digitorum superf cialis. The most requent cause o median nerve compres sion is dynamic compression o the nerve between the two heads o the pronator teres muscle, exacer bated by orearm pronation and elbow extension. There are a large number o muscles arising rom the elbow, whose main unction is to control move ment o the wrist and hand. Many muscles merge to attach to the medial and lateral epicondyles, through common tendinous attachments. These structures are susceptible to overload and degeneration that
requently result in pain. Lateral epicondylalgia is reported as up to our to seven times more common than medial epicondylalgia, or gol er’s elbow (Rineer & Ruch 2009). The higher prevalence o lateral elbow pain may be due to a number o actors, including di erences in orces generated by the extensor muscles as well as di erences in size o the tendons area o insertion.
Subje c tive e xaminatio n The f rst questions the therapist should ask the patient are: ‘what is your main problem?’; ‘what do you think will happen to you?’; ‘what do you think therapy can do or you?’; and ‘do you ear harm rom physical activity?’. Knowing the patient’s attitudes and belie s towards their problem requently directs the rest o the examination. These simple questions may alert the astute therapist to the possibility o yellow ags, or psychosocial issues, which require urther questions and ultimately to more ormal psychosocial screening instruments. Psychosocial actors o a eeling o low job control and low social support are associated with symptoms o lateral epicondylalgia (van Rijn et al. 2009). Further more signif cant anxiety and depression were detected in 55% and 36% o patients with chronic lateral epicondylalgia, respectively (Alizadehkhaiyat et al. 2007a). Physiotherapists have been shown to have di f culty in detecting intuitively psychological risk actors such as ear avoidance (Calley et al. 2010). In contrast a simple question such as ‘Are you a raid physical activity will cause an increase in your pain?’ has been shown to be help ul in iden ti ying people with ear avoidance and catastrophiza tion (Calley et al. 2010). Failure to identi y these issues is likely to lead to treatment ailure, as is the case in other musculoskeletal disorders such as low back pain.
Body chart A detailed body chart is an important f rst step to identi y the potential source o the patient’s symp toms. The nature o the symptoms and their loca tion may help the therapist to decide which pain mechanisms are predominant (nociceptive, peri pheral neuropathic, central mechanisms) (Smart et al. 2010). In the previous edition o this book 263
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(H engeveld & Banks 2005), it has been suggested that local sources are more likely to be the origin o the symptoms i the symptoms are collectively: 1. Consistent (predictable pain response to activity) 2. Familiar (described as being a joint like ache) 3. Specif c (easily localized in areas o recognizable neuromusculoskeletal structures). In contrast, re erred pain rom remote sources will be vague, and more di f cult to localize, with spread proximally. Symptoms should ollow a predictable response to activity involving the spine or shoulder. Pain with a dominance o central mechanisms may be suspected (Smart et al. 2010) i the symptoms are collectively: 1. Inconsistent and activity provokes exaggerated responses 2. Di use, non specif c, widespread and spreading to other body regions outside the upper limb a ected 3. Spontaneous and paroxysmal. In addition to the words the patient uses to describe the symptoms, non verbal cues may also enhance the physiotherapist’s hypothesis about the disorder. For example, the patient may point precisely to the location o the pain or may use the whole hand to describe a broad area o symptoms or one f nger may ollow the course o a peripheral nerve. These non verbal cues may provide urther evidence or a local or remote structure as the pain source. It may be possible or the patient to determine the depth o symptoms. Deep pain over a particular joint line may give indication about structural involvement. Superf cial pain over a muscle belly or tendon may be one actor in determining a struc tural diagnosis. Pain arising rom sensitized neural tissue is elt deep, probably because the axons that become mechanosensitized are those that supply deep structures (Bove et al. 2003, 2005). While it is tempting to believe that physiotherapists can identi y the pain source rom detailed questioning, the validity o these assumptions has not been tested. Certain areas o symptoms are quite common to specif c local elbow structures and are described in Table 5.1. Where pain is re erred into the elbow rom other sources a relationship between symptoms and move ment in these other areas and the elbow symptoms should be established. 264
Table 5.1 Elbow symptoms associated with local structures
Elbow symptoms
Local structures
Medial part of the lateral epicondyle
Common extensor origin
Radiohumeral joint line/ posterior aspect of the head of radius
Radiohumeral joint, annular ligament, radioannular joint
Band of pain across the elbow
Radiohumeral, humeroulnar joints
Deep anterior pain
Radiohumeral, humeroulnar, superior radioulnar and median or radial nerves
Surface anterior
Anterior capsule, biceps
Medial epicondyle
Common exor origin
Ulnar notch
Ulnar nerve
Behaviour o s ymptoms A detailed knowledge o the behaviour o the patient’s elbow symptoms with movement will help the clinician to decide which movements are impaired and which are likely to reproduce the patient’s pain when examined. Furthermore, the ease with which the symptoms are reproduced pro vides in ormation about the scope the therapist has to examine the elbow and the care required to avoid excessive provocation o the symptoms. The aggravating activities provoking pain may give clues that can help establish whether the problem is movement related or not. Consequently, those activities causing symptoms may also help to identi y the pain source. For example, the patient may report di f culty when: exing the elbow to dress independently; supinating the orearm to take coins out o a pocket; or extending the elbow to reach to a high shel or to push open a door. All these unctions indicate potential or local joint dys unction. An example o pain arising rom tendon or con tractile structures is a report o medial or lateral epicondyle pain when wringing out a wet towel, or gripping and twisting a heavy door handle. An example o remote structure involvement is lateral elbow pain brought on by a neural provocative
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position, such as reaching through to the back seats o the car or carrying a heavy bag on one shoulder, or in one hand. Less specif c pain, such as aching around the elbow that is not brought on by specif c elbow movements or activities, is more likely to be re erred pain. Where possible the most specif c provocative movement should be identif ed as this provides in ormation about the movement that should be examined in detail. It also provides in or mation regarding treatment e f cacy and direction or progression. Where possible the level o unctional impair ment that the patient is experiencing must be quan tif ed. This in ormation is invaluable in determining the level o disability at the outset o the treatment programme and serves as a measure o change or treatment progress. There have been at least f ve patient sel rated questionnaires described to evalu ate elbow disability; however, not all have been vali dated (Longo et al. 2008). Use ul questionnaires include the Disabilities o Arm, Shoulder, and H and (DASH ) and Patient Specif c Functional Scale (PSFS). The PSFS is not specif c to the elbow and can be used or any body region, and is there ore easy to remember and easy to score. Construct validity has been demonstrated or the DASH scale (G ummesson et al. 2003, Slobogean et al. 2010). Likewise the PSFS has been shown to be a valid and reliable measure o disability and has been shown to be more sensitive to change ollowing treatment than other measures o disability, pain and physical impairment (Donnelly & Carswell 2002, Pengel et al. 2004). The minimal clinically impor tant change or the PSFS has been reported as 2.0 (Cleland et al. 2006). For the DASH questionnaire the minimal detectable change is 10.5 and the minimal clinically important change is 10.2, where ull unction is 100.0 (Roy et al. 2009). A short orm o the DASH questionnaire has been developed which is more use ul than the long orm, in the rush o daily clinical practice (Angst et al. 2009). I the patient can consistently demonstrate an activity or movement that reproduces the symp toms, the potential or structural di erentiation is enhanced. For example, i a patient experiences lateral elbow pain, while clenching the f st with the elbow extended and the orearm pronated, the ol lowing tests may be considered to isolate the pain source:
• In standing, ask the patient to make a f st with the arm by the side, then with the arm in 90°
shoulder abduction and internal shoulder rotation, ollowed by contralateral cervical exion and scapula depression. Successive changes in arm position increases the stress on the neural structures in the upper limb, in particular the radial nerve. I the symptoms increase with the concomitant increase in stress applied to the neural system then peripheral nerve sensitization may be postulated and urther examination should ocus on this (H all & Elvey 2011). • In a supine lying position, push the radius cephalad, so that the head o the radius is compressed against the capitulum. I this manoeuvre increases the symptoms signif cantly, the radiohumeral joint may be considered or urther examination. • I the only actor which alters the patient’s symptoms is the strength o the grip and pain is only reproduced on active contraction o the extensor muscles, and during palpation o the common extensor origin, the most likely source o impairment will be o the extensor muscle apparatus. Pain and sti ness produced in the elbow primarily with a exion or extension movement would sug gest urther investigation o the radiohumeral and humeroulnar joints in particular. Pain and sti ness with activities involving pronation or supination suggest that urther investigation o the radio humeral, and radioulnar joints is warranted. Elbow pain associated with prolonged computer keyboard use or other relatively f xed postural activity is o ten associated with poor postural and motor control o the spine and scapula. Alternatively peripheral entrapment or mechanosensitization o nerve trunks around the elbow, or in more proximal sites, must also be considered. Elbow pain with weight bearing activities through the arm may indicate the need to use compression tests o the elbow joints within examination and possibly treatment to have a better chance o repro ducing and a ecting the pain experienced. H igh speed movement o the elbow may be the only pain provocative activity. Pitching in baseball, hurling a javelin, or throwing a cricket ball o ten causes pain in the posterior and medial elbow. Care ul examination o the throwing action will be required, together with analysis o the humeroulnar joint. Elbow collateral ligament stability testing may also be required. 265
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His tory (pres ent epis ode and its progres s ion s ince ons et and pas t epis odes and their natural his tories ) There are numerous and varied causes or the onset o elbow symptoms. For example, traumatic intra articular ractures or osteochondral de ects cause immediate pain and disability, but may also alter the geometry o the elbow joint, leading to long term pain and joint sti ness (Nandi et al. 2009). Alternatively, degenerative arthropathies or tendinopa thies may result in recurrent episodes o pain, which usually recover over a period o time. Episodes o elbow pain and dys unction may also ollow unusual, prolonged, repetitive or orce ul activity such as throwing a ball or the f rst time, repeatedly or with excessive orce. O veruse o the wrist and hand, such as in industrial or repetitive manual tasks, may explain proximal orearm and elbow symptoms (Silcock & Rivett 2004). A previous history o upper limb injury or pain, not just in the elbow, may explain why the elbow has become symptomatic in individual cases. As is the situation with other musculoskeletal pain disorders, in the majority o cases o elbow pain, the cause o the problem is not specif c and there is no recognizable pathology. I symptoms are prolonged or there is recurrence with little evidence o mechanical or stress ul triggers, then the identi f cation o the actual and potential barriers to recov ery should be considered. Potential barriers to the recovery o severe pain include work related disease, length o history o the disease, ergonomic risk exposure, job stress, level o job support and pain coping style (Feuerstein et al. 2000). O ther reports o barriers to recovery also include the psychological status o the patient. Alizadehkhaiyat et al. (2007a) ound elevated levels o depression in 55% and anxiety in 36% o people su ering rom lateral epi condylalgia. H ence, it is important to view elbow problems as a biopsychosocial disorder, rather than a purely biological dys unction. The psychological status o the patient must be considered. In addition to the psychosocial status, there may be the potential or prolonged symptoms due to a number o related physical issues, which detailed examinations may identi y. The presence o neural symptoms in the arm and cervical joint signs has been associated with poor short–term outcome ol lowing local elbow treatment or lateral epicondyla lgia (Waugh et al. 2004). H ence, examination o the 266
spine including the rib cage, is important at least in the management o lateral epicondylalgia (Cleland et al. 2004). Altered posture o the upper limb and abnormal patterns o motor control may be risk actors or the development o pain and maybe involved in prolonging recovery. Kelley et al. (1994) identif ed in subjects with lateral epicondylalgia marked dys unction o orearm muscle activation, especially o the extensor carpi radialis muscles, along with qualitatively determined altered kine matics o the upper limb when compared with healthy controls. Q uantitative evidence o altered postural and motor control in lateral epicondylalgia has also recently been demonstrated (Bisset et al. 2006b).
Special ques tions Routine special questions provide in ormation about the potential or serious pathology and should be included in the screening o the patient’s condi tion. O interest are the patient’s recent general health status, related weight loss, the medication they have been prescribed and any medical imaging procedures that have been undertaken. Further in ormation regarding special questions is given in Chapter 1.
Evide nc e -bas e d prac tic e with re fe re nc e to manual the rapy Manual therapy or the elbow consists o a wide range o di erent mobilization or manipulation techniques (MWM), as well as taping procedures and exercise. Although no studies have directly investigated the e f cacy o the Maitland Concept or the management o elbow pain disorders, a number o studies have investigated other orms o manual therapy. Lateral epicondylalgia is the most common elbow condition in adults (H ong et al. 2004) a ecting up to 3% o the general population, with higher incidence in manual occu pations (Shiri et al. 2006). It is not surprising that this condition has been most commonly investi gated or manual therapy interventions, probably in part due to the ease in identi ying subjects or study inclusion. Mulligan MWM is the most requently studied manual therapy intervention or lateral epicondylal gia (H erd & Meserve 2008). These studies had the
Evid e n c e - b a s e d p ra c tic e w ith re fe re n c e to m a n u a l th e ra p y
highest quality research methodology rating scores (PEDro score 6.2/ 10) when compared to studies investigating other orms o manual therapy (H erd & Meserve 2008). Pagorek (2009) reviewed the evidence or MWM and ound overall that there was strong evidence that MWM reduces pain and increases grip and other muscle strength parameters in people who su er rom lateral epicondylalgia. This review was limited to studies published between 2001 and 2008. From a database search the author identif ed two randomized controlled trials, one cohort study and two case series meeting the inclusion criteria. Not included in this review was a randomized controlled trial comparing MWM with exercise, to therapeutic ultrasound with exercise and to a control group (Kochar & Dogra 2002). The MWM group showed signif cantly greater improvement than both the ultrasound group and the control group on pain, weight li t test, and grip strength. The MWM group showed improvement on most parameters rom the f rst week onwards. An addi tional investigation compared the e ect o MWM combined with Mulligan taping techniques to tra ditional orms o treatment (Amro et al. 2010). Consistent with previous investigations, this study revealed signif cantly greater improvement in pain and grip strength in subjects who received the Mulligan approach. Evidence is available to support benef cial e ects o cervical mobilization and manipulation or the treatment o lateral epicondylalgia. Two studies have demonstrated (Vicenzino et al. 1996, 1998) that a cervical mobilization has immediate positive e ects on pain ree grip strength, pressure pain threshold and neurodynamics. In addition, it has been reported (Fernandez Carnero et al. 2008) that a single appli cation o a cervical high velocity thrust had similar e ects. H owever, no long term ollow up assess ment was included. O ne study (Cleland et al. 2004) o high methodological quality (H erd & Meserve 2008) demonstrated that the addition o cervical spine mobilization to a treatment regimen including manual therapy and exercise directed at the elbow and wrist resulted in signif cant improvements in pain ree grip, pain, disability, and patient rated treatment satis action when compared with local treatment to the elbow. O utcomes or the cervical mobilization group were ound to be superior both at discharge and at six month ollow up. Thus, the inclusion o the cervical spine in management o lateral epicondylalgia is supported.
Evidence is also available to support the use o manipulative techniques at the wrist or managing lateral epicondylalgia (see Fig. 5.65). Struijs et al. (2003) examined the e ectiveness o wrist manipu lation compared to local elbow management consist ing o riction massage, ultrasound and exercise. This study’s f ndings supported the use o wrist manipulation in management, with signif cant ben ef ts demonstrated or at least six weeks ollowing treatment. In terms o manual therapy directed to the elbow region, one study, rated as only air methodological quality (H erd & Meserve 2008), examined the e ectiveness o neural mobilization combined with radial head mobilizations when compared to stand ard treatment or lateral epicondylalgia (Drechsler et al. 1997). AP radial head mobilization was carried out in a degree o neural provocation or the radial nerve (in elbow extension with shoulder internal rotation and abduction). Results avoured the com bined treatment over standard treatment at dis charge and up to three months’ ollow up. Exercise has also been shown to be benef cial or lateral epicondylalgia (Bisset et al. 2005). The primary physical impairment is a deconditioning response to pain (Vicenzino 2003). H ence, general strengthening exercises should be considered or the whole upper limb. At least exercises should include strengthening o the orearm muscles con trolling wrist/ f nger exion and extension, as well as supination/ pronation and radial/ ulnar deviation. Furthermore, stretching exercises or the muscles around the orearm should be considered, in addition to re education o motor control o the wrist during gripping activities (Bissett & Vicenzino 2011). An eight week exercise programme provided positive benef ts in a chronic population, who had ailed other conservative treatments, including cor ticosteroid injection (Pienimaki et al. 1996). Similarly researchers ound that, compared with an ultrasound treatment, exercise resulted in ewer medical consultations, less surgery and ewer sick days (Pienimaki et al. 1998). Likewise, a randomized controlled trial revealed that a supervised exercise programme brought about the largest reduction o pain and improvement in unction through a six month ollow up period, compared with Bioptron light therapy and Cyriax physiotherapy techniques (Stasinopoulos & Stasinopoulos 2006). H ence, it is apparent rom this brie review o the literature that lateral epicondylalgia may be 267
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managed by a number o di erent treatment approaches. This is in no way a weakness o manual therapy. Rather, it probably indicates that lateral elbow pain is a multisystem problem a ecting the local elbow and remote articular, neural and musculotendinous structures. Di erent manual therapy concepts and treatment techniques may address di erent components o lateral epicondyla lgia. Further research is required to investigate whether treatment matched to clinical assessment f ndings o all potentially involved structures pro vides any additional benef t over a more prescriptive approach. Recently it has been shown that pain accounts or between 41–66% o the variability in disability ollowing elbow trauma (Doornberg et al. 2005, Lindenhovius et al. 2008). In contrast, physical impairment in elbow movement only accounts or between 17–35% (Doornberg et al. 2005, Lindenhovius et al. 2008). This evidence strengthens the case or a multisystem biopsychosocial approach to the examination and management o elbow
disorders. Clinical evaluation should encompass evaluation o pain, disability, psychosocial barriers to recovery, as well as a detailed physical exami nation. Physical examination includes the elbow joints accessory, physiological and combined move ments. In addition, evaluation should encompass upper quarter dynamic postural and motor control, as well as simple tests o elbow muscle unction. Including detailed examination o the cervical and thoracic spine, upper limb neurodynamic tests and neurological unction will only serve to enhance the diagnostic, treatment and management role o manual therapy in elbow disorders.
Phys ic al e xaminatio n: e lbo w re g io n The ollowing is a checklist or an integrated approach to the physical examination o the elbow region, as summarized in Boxes 5.1–5.4 (Maitland 1992).
Box 5 1 Physical examination of the composite elbow Ob s e rva tion
Di erentiating as required
*Functional demons tration/tes ts
1 F and E as IV+ at limit o range a F/Ab, F/Ad, E/Ab, E/Ad Ab and Ad in the rs t 5° o F and ull E b (in line with humerus ) ceph and caud (i) on radius (radiohumeral) (R/H) joint or s uperior radioulnar (R/U) joint add s uperior R/U compres s ion to di erentiate between R/H and s uperior R/U (ii) on ulna (humeroulnar joint) c (in line with radius ) ceph and caud (i) on radius (R/H or s uperior R/U joint) add s uperior R/U compres s ion to di erentiate between R/H and s uperior R/U (ii) on ulna (humeroulnar joint) 2 Sup and Pron as IV+ at limit o range a , on head o radius (s uperior R/U or R/H joint) add compres s ion o s uperior R/U joint to di erentiate between radiohumeral and s uperior R/U joint b , on ulna (humeroulnar joint)
• • •
Their demons tration o their unctional movements a ected by their dis order Di erentiation o their demons trated unctional movement(s ) Dynamic upper limb motor control
Brie f a p p ra is a l Active movements (move to pain or move to lim it) • • •
F, E (as applicable, bouncing F and E in ull pronation and s upination) Sup, Pron (as applicable, per ormed in F and E) Active neurodynamic s creening tes ts
Is ometric/mus cle length tes ts Other structures in ‘plan’ • •
Thoracic outlet/cervical radiculopathy Peripheral nerve involvement
Pas s ive movements As applicable •
F, E; Sup and Pron as IV− to IV+ to III++
268
P h ys ic a l e xa m in a tio n : e lb o w re g io n
Box 5 1—cont’d 3 Other di erentiating tes ts • (a) , , , , , on head o radius in di erent pos itions o elbow F and E • (b) , on olecranon and coronoid 4 Combined movements 5 Di erentiation tes ts 6 Neurodynamic tes ts or the median, radial and ulnar nerves
Palpation •
+ When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ • Relevant tendernes s (ulnar and median nerve) Check cas e records etc Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission from Maitland 1992.
Box 5 2 Physical examination of the radiohumeral joint The routine examination o this joint mus t include examination o other joints orming the elbow
Is ometric/mus cle length tes ts
Ob s e rva tion
Other structures in ‘plan’
*Functional demons tration/tes ts • •
Their demons tration o their unctional movements a ected by their dis order Di erentiation o their demons trated unctional movement(s ) Dynamic upper limb motor control
•
• •
Mus cles in ‘plan’ including clenching s t in di erent pos itions o elbow Thoracic outlet/cervical radiculopathy Peripheral nerve involvement
Pas s ive movements Routinely
Active movements (move to pain or move to lim it) Routinely
1 F, E; Sup and Pron in F and E 2 ceph and caud (by wris t deviations ) in di erent angles o elbow rom ull F to ull E, and ull s upination to ull pronation 3 , in di erent pos itions o F, E, Sup, Pron, without compres s ion and with compres s ion Note range, pain, res is tance, s pas m and behaviour
• • •
1 Di erentiation tes ts 2 Neurodynamic tes ts or the radial nerve
•
Brie f a p p ra is a l
F, E; Sup and Pron in F and E Note range, pain Active neurodynamic s creening tes ts
As applicable
As applicable
Palpation
• • • • • •
•
Speed o tes ts movements Speci c movements which aggravate The injuring movement Movements under load Cervical radiculopathy tes ts Mus cle power
+ When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ • Relevant tendernes s (radial nerve) Check cas e records etc Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission from Maitland 1992.
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Box 5 3 Physical examination of the humeroulnar joint The routine examination o this joint mus t als o include examination o the s uperior radioulnar (R/U) joint as s upinator/pronator tors ion is pos s ible at the humeroulnar joint
Ob s e rva tion *Functional demons tration/tes ts • • •
Their demons tration o their unctional movements a ected by their dis order Di erentiation o their demons trated unctional movement(s ) Dynamic upper limb motor control
Brie f a p p ra is a l
Pas s ive movements Physiological m ovem ents Routinely •
F, E; Sup and Pron in F and E Note range, pain, res is tance, s pas m and behaviour As applicable • E/Ab, E/Ad, F/Ab, F/Ad, Ab and Ad in 5° F and E
Accessory m ovem ents As applicable 1 2
Active m ovem ents (m ove to pain or m ove to limit) Routinely • • •
F, E; Sup and Pron in F and E Note range, pain Active neurodynamic s creening tes ts
3 4
As applicable • • • • • •
Speed o tes ts movements Speci c movements which aggravate The injuring movement Movements under load Thoracic outlet/cervical radiculopathy tes ts Mus cle power
Is ometric/mus cle length tes ts •
Mus cles in ‘plan’ including clenching s t in di erent pos itions o elbow
Other structures in ‘plan’ • •
Thoracic outlet/cervical radiculopathy Peripheral nerve involvement
5 6
, (i) on olecranon (ii) on coronoid caud (humeral line) in 90° elbow F • (i) on olecranon (thumbs ) • (ii) on coronoid (thumbs ) • (iii) general humeral line F over wris t in anterior elbow line ceph, caud ulnar line (with wris t deviations ) in di erent angles o elbow F and E Note range, pain, res is tance, s pas m and behaviour Di erentiation tes ts Neurodynamic tes ts or the median, radial and ulnar nerves
Palpation • •
Altered s ens ation Relevant tendernes s (ulnar, radial, and median nerve) • When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ Check cas e records etc Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission from Maitland 1992.
In s tanding • O bservation o :
○ alignment aults: rom ront, back and side ○ asymmetry: adaptive and protective
de ormity ○ so t tissue changes: swelling, thickening ○ bone structure: olecranon, epicondyles. • Present pain. • Functional demonstration/ active unctional movements and di erentiation. • I necessary tests – elbow. 2 70
• Brie appraisal/ screening o shoulder range o movement and dynamic control. • Active screening or median, radial and ulna nerve peripheral sensitization (H all & Elvey 2011).
In s itting • Cervical spine brie appraisal/ screening tests o single plane and combined movements. • Screening or cervical radiculopathy using lower cervical quadrant (Maitland et al.
P h ys ic a l e xa m in a tio n : e lb o w re g io n
Box 5 4 Physical examination of the superior radioulnar joint The routine examination o this joint mus t als o include examination o the humeroulnar and radiohumeral joints
Ob s e rva tion *Functional demons tration/tes ts • • • •
Their demons tration o their unctional movements a ected by their dis order Di erentiation o their demons trated unctional movement(s ) Dynamic upper limb motor control Active neurodynamic s creening tes ts (radial nerve)
Brie f a p p ra is a l Active movements (move to pain or move to lim it) •
As des cribed or the elbow joint
Is ometric tes ts Other structures in ‘plan’ • •
Thoracic outlet/cervical radiculopathy Peripheral nerve involvement
Accessory m ovem ents Routinely 1 Ab and Ad o elbow in 5° F (Sup R/U) 2 ceph, caud (ulnar line) in di erent angles o elbow F and E and di erent angles o Sup and Pron (us ing wris t deviations ) without compres s ion and with compres s ion 3 and and each in ull pronation and ull s upination 4 Supination/pronation with compres s ion As applicable 1 Di erentiation tes ts 2 Neurodynamic tes ts or the radial nerve
Palpation •
+ When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ • Relevant tendernes s (radial nerve) Check cas e records etc Highlight m ain f ndings with asterisks Ins tructions to patient
Pas s ive movements Physiological m ovem ents •
As or elbow joint
Reproduced by kind permission from Maitland 1992.
2001), incorporating axial compression i required. • Thoracic spine brie appraisal/ screening (Maitland et al. 2001). • G rip strength, pain provocation and pattern o motor control in ull elbow extension with orearm pronation.
In s upine • Palpation or hyperalgesia (joint lines, peripheral nerves, common exor and extensor origins in particular). • Isometric testing: (1) grip strength in elbow extension; (2) wrist extension; (3) individual metacarpal extension, especially the third, which is the insertion site or extensor carpi radialis brevis. • Muscle length: (1) f nger extensors; (2) wrist extensors; (3) f nger exors; (4) wrist exors; (5) biceps length; (6) triceps length.
• Elbow passive movements. • Elbow extension, extension/ adduction, • • • • • • • • •
extension/ abduction. Elbow exion, exion/ adduction, exion/ abduction. Pronation/ supination. Di erentiation tests in exion/ extension or pronation/ supination. Accessory movements: radiohumeral, radioulnar, humeroulnar. MWM: pain ree accessory glide combined with dominant dys unctional elbow movement or activity. Cervical anteroposterior movement (Maitland et al. 2001). Shoulder quadrant and locking position. Brie appraisal tests/ screening wrist and hand and in erior radioulnar joint. Upper limb neurodynamic and nerve palpation tests (H all & Elvey 2011). 2 71
C H AP TE R 5
Manag e me nt o f e lbo w dis o rde rs
• C3–C7 passive physiological intervertebral
• Fractures or def nite trauma o ten present with
movements (PPIVMs) (Maitland et al. 2001). • Neurological examination or peripheral nerve compression or radiculopathy.
swelling or bony de ormity. • Prominence and local swelling o the medial or lateral epicondyle may be a eature o acute epicondylalgia. • Antalgic postures may include holding the elbow exed to avoid pain ul extension or keeping the orearm pronated to avoid pain ul supination. Antalgic postures or sensitized neural structures include holding the elbow exed, with the shoulder girdle elevated and adducted.
In s ide lying • C7–T4 PPIVMs (Maitland et al. 2001).
In prone lying • O lecranon accessory movements in elbow exion. • Posteroanterior movement o the head o the radius in elbow extension. • Passive accessory intervertebral movements (PAIVMs) cervical and thoracic spine. • Rib accessory movements, rib springing (Maitland et al. 2001).
Precautions and planning • Explanation: The patient should be in ormed at every stage o examination and treatment. The therapist should in orm the patient, as ar as is possible, about the nature o the problem, the options or treatment (including benef ts and risks) and the expected responses to treatment. • Warning: A ter examination (and f rst treatment) the patient should be warned that there may be some treatment soreness over the next day or so. This is because the joint has been moved, both during examination and treatment, in ways that it has not been moved be ore or or a while. • The therapist should check the case notes and medical imaging and plan treatment and reassessment.
Phys ic al e xaminatio n: the e lbo w c o mple x Obs ervation • In most cases patients with insidious onset elbow pain will have no obvious visual abnormalities o the elbow itsel . H owever, there may be evidence o poor posture o the shoulder girdle and spine. 2 72
Functional demons tration/injuring movements /active unctional movements and di erentiation o thes e movements (to P 1 or limit) O bserve or abnormalities in quality o movement and common alignment aults; or example, the patient may externally rotate and adduct the shoul der to avoid having to supinate the orearm. For overuse disorders there may be subtle signs o poor control, involving the whole upper limb kinetic chain (Ellenbecker et al. 2010a), and these should be evaluated in detail. I elbow pain is reproduced during grip strength testing, but is relieved by MWM, such as a lateral glide or PA glide on the radius, this should be incor porated into unctional rehabilitation. Active movements or brief appraisal o the elbow should include exion, extension, pronation and supination (Figs 5.1–5.4). I active movement is pain ree, the patient can be asked to ick the elbow urther into the movement as a means o applying natural overpressure. O nly i the patient has a consistent, reproducible unctional demonstration will urther di erentiation be possible. A patient with deep anterior elbow pain may demonstrate that the pain is always elt when the elbow is exed rom 75° to 95°. I the pain ul movement is repeated with compression or distraction o the radiohumeral joint, compres sion or distraction o the humeroulnar joint or repeated exion/ extension movement in di erent positions o pronation/ supination, a more accu rate localization o the source o the symptoms will help in the choice o treatment technique (Figs 5.5–5.8).
Fig ure 5.1 • Elbow exion.
Fig ure 5.3 • Elbow supination.
Fig ure 5.2 • Elbow extension.
Fig ure 5.4 • Elbow pronation.
Fig ure 5.5 • Elbow exion to 75°.
Fig ure 5.7 • Humeroulnar compression.
Fig ure 5.6 • Radiohumeral compression.
Fig ure 5.8 • Different positions of pronation/ supination.
P h ys ic a l e xa m in a tio n : th e e lb o w c o m p le x
A patient with lateral elbow pain may demon strate that the pain is always elt when twisting (pronating) the orearm while using a screwdriver (loaded). I the pain ul movement is per ormed with radiohumeral compression or distraction, supe rior radioulnar joint compression or in di erent positions o exion and extension, an accurate treat ment technique can be determined (Figs 5.9–5.13). A patient with lateral epicondylalgia may com plain o pain when gripping a gol club. The patient may be able to demonstrate, consistently, the repro duction o this pain. In the pain ul position acces sory movements on the head o the radius may reveal pain or sti ness, indicating articular involve ment. Likewise, pain elimination while eliciting a sustained glide on the radius (Fig. 5.14) or ulna (Fig. 5.15) indicates the potential or MWM in manage ment. H ence, any change in pain on gripping, when
Fig ure 5.9 • Radioulnar pronation.
mobilizing the radius, is important. In the pain ul position, the addition o shoulder depression and contralateral cervical lateral exion may reveal abnormality o radial nerve mechanosensitivity (Fig. 5.16). Dys unction o cervical active range o motion in the cardinal planes or o combined movement tests raises the importance o urther tests o the cervical spine. An increase in pain with isometric testing o wrist and f nger extension (in the absence o any other movement related signs or neural involvement) may suggest musculotendinous origins to the patient’s symptoms.
I neces s ary tes ts Frequently elbow pain is associated with vigorous sporting activity or injury. In such cases it may only
Fig ure 5.10 • Radiohumeral compression added.
2 75
Fig ure 5.11 • Radiohumeral distraction added.
Fig ure 5.12 • Different positions of exion/extension.
Fig ure 5.13 • Superior radioulnar compression added.
P h ys ic a l e xa m in a tio n : th e e lb o w c o m p le x
Fig ure 5.14 • MWM radius pain on gripping golf club – PA radius.
Fig ure 5.15 • MWM ulna pain on gripping golf club lateral glide.
Upper limb dynamic control
Fig ure 5.16 • Neural differentiation.
be possible to reproduce the patient’s pain by asking them to per orm the o ending activity at speed (throwing a cricket ball or equivalent), repeatedly (table tennis backhand) or or a sustained period (gripping a ski pole).
In those people where elbow pain arises rom repetitive stress or overuse, care ul consideration should be given to the posture and dynamic control o the whole upper kinetic chain (Ellenbecker et al. 2010ab). Such poor control may place abnormal stress on the elbow, hence may be a contributing actor towards the cause o the problem or may also provide a barrier towards recovery. There is evidence to support this idea. Silcock et al. (2003) ound evidence o altered upper limb muscle activity during various arm movements in people with lateral elbow pain when compared to asymptomatic controls. Dys unctional muscles included those around the elbow and wrist, but also included pectoralis major and middle trapezius. O ther studies have also ound evidence o altered motor control in people with lateral elbow pain (Bisset et al. 2006b, Pienimaki et al. 1997). It is unclear whether poor control is a consequence or cause o pain. H owever, it would appear logical that poor posture and dynamic control o the upper limb impacts on the elbow. Indeed, poor cervical and shoulder girdle posture has been linked with a range o upper limb dis orders including the elbow (Pascarelli & H su 2001) in addition to more distal problems such as carpal 2 77
C H AP TE R 5
Manag e me nt o f e lbo w dis o rde rs
tunnel syndrome (De la Llave Rincon et al. 2009, Pascarelli & H su 2001). Evaluation o scapula dynamic control can be determined through the observation o shoulder elevation through exion and abduction (Tate et al. 2009, Uhl et al. 2009). Increasing load during these movements with small hand weights may also be benef cial in emphasizing poor scapula control. This method o determining poor control has been shown to be reliable (McClure et al. 2009). In addition to the shoulder girdle, it is important to evaluate the control o the wrist during gripping activities. During grip strength tests, patients with lateral epicondylalgia typically ex the wrist by an average o 11° more than asymptomatic people (Bisset et al. 2006b). This may be due to weakness o the extensor carpi radialis (Alizadehkhaiyat et al. 2007b). People who su er with lateral epicondyla lgia are generally weaker in selected upper limb movements, probably due to pain inhibition or disuse (Alizadehkhaiyat et al. 2007b). Consequently, caution should be taken when interpreting strength di erences on the symptomatic side compared to normal values or the non involved side. Bisset et al. (2006b) ound increased strength values on the non involved side in lateral epicondylalgia compared to healthy controls. This f nding may indicate a com pensatory mechanism or may re ect an underlying cause o this condition.
Mus cle is ometric and length tes ting The goal o muscle isometric and length testing is to evaluate or the presence o muscle disorders, either o the contractile f bres or o the muscle origin and insertion. Caution is necessary when interpreting pain as a consequence o isometric muscle tests. Muscle contraction may stress sensitized neural tissue or compress pain ul joints. These tests should be viewed in the context o the whole physical examination. Isometric testing as a pain provocation procedure is required in cases o medial and lateral elbow pain when gripping and/ or loaded wrist or f nger exion or extension are pain provocative. The best position or isometric testing is with the patient lying supine. For pain over the lateral epicondyle the elbow should be ully extended and pronated. Pronation is thought to exert more tension on the common extensor origin. Commonly the middle f nger reproduces lateral elbow pain 2 78
most readily when resisted isometrically in wrist extension. Extensor carpi radialis longus and brevis attach to the third metacarpal and provides the most extensive component o the common exten sor origin (Standring 2008). H igh levels o stress in the extensor carpi radialis brevis musculo tendinous unit, has been suggested to be the cause o pain in overuse disorders o lateral epi condylalgia (Coombes et al. 2009). For medial elbow pain the exor carpi radialis is most com monly involved and testing should involve wrist exion and pronation. Muscle length testing should be undertaken as required or muscles passing over the elbow such as the f nger extensors and exors, as well as muscles acting on the elbow such as biceps and triceps.
Palpation Palpation requires an accurate knowledge o sur ace anatomy. Figure 5.17 shows some relevant sites or palpation o the elbow, including joint lines, periph eral nerves and myo ascial structures. Abnormal sensitivity to gentle palpation (allody nia, secondary hyperalgesia) at sites around the elbow in the absence o signs o tissue damage or in ammation may be due to central mechanisms, with an increase in central sensitization, or may be re erred tenderness rom the spine (Blake & Beames 2012).
Upper limb neurodynamic tes ts , nerve palpation and neurological examination There is potential or neural disorders to contribute to elbow pain and unctional disability (H ariri & McAdams 2010). Such disorders need to be di erentiated according to underlying pathophysiologi cal mechanisms (H all & Elvey 2011). Neural disorders can be classif ed according to clinical examination criteria into three categories: neuro pathic sensory hypersensitivity (NSH ); compressive neuropathy (CN); and peripheral nerve sensitization (PNS) (Schä er 2009a). Classif cation is important because each subgroup has been shown to respond di erently to neural mobilization. In the lower limb at least, PNS responds avourably to neural mobili zation, while NSH does not (Schä er et al. 2011).
P h ys ic a l e xa m in a tio n : th e e lb o w c o m p le x
Similarly in the upper limb, people with clinical eatures o NSH have been shown to respond poorly to manual therapy (Sterling et al. 2006). Neuropathic sensory hypersensitivity encompasses major eatures o neuropathic pain, comprising sensory sensitization such as allodynia, hyperalgesia and par oxysmal pain. CN arises rom signif cant axonal and ascicular compromise with marked sensory and/ or motor def cits. PNS develops rom nerve trunk in ammation, which causes nervi nervorum and axonmechanosensitivity (Bove & Light 1997, Bove et al. 2003, Dilley et al. 2005). Clinical classif cation o neural pain disorders is hierarchical. First the Leeds Assessment or Neuro pathic Symptoms and Signs (LANSS) scale (Bennett 2001) is used to determine the presence o positive eatures o NSH . I the LANSS scale is negative (less than 12), then the neurological examination (Blake & Beames 2012) is used to identi y the presence o CN. Finally in the absence o CN, collectively active neurodynamic screening tests,
Radiohumeral joint line
Annular ligament Common extensor origin
Olecranon
Olecranon fossa Common extensor origin Radiohumeral joint line Annular ligament
Fig ure 5.17 • Palpation sites, lateral elbow pain.
passive neurodynamic tests and nerve palpation (Blake & Beames 2012) indicate the presence o substantial PNS. Reliability o this classif cation system has been demonstrated in the lower limb (Schä er et al. 2009b) and there is some evidence o validity at least in people with lumbar related leg pain (Schä er et al. 2009c, 2013). With respect to symptoms in the elbow region, the most relevant categories are CN and PNS. All three major nerves cross the elbow where they may be vulnerable to compression orces and/ or in am mation (H ariri & McAdams 2010). H ence it is important to consider neural disorders o the median, radial, and ulnar nerves. The ulnar nerve should be examined i the patient complains o medial elbow pain and symp toms in the distribution o the ulnar nerve. For example, a patient may complain o medial elbow pain and paraesthesia in the little f nger as a result o throwing a baseball, thus suggesting a potential or ulnar nerve involvement. Distinguishing between a true compression neuropathy (CN) and PNS o the ulnar nerve requires comprehensive examina tion o the elbow and cervical spine. A neurological examination must be conducted to determine the presence o CN, which may arise rom localized compression in the cubital tunnel, or more proxi mally in the cervical spine or thoracic outlet. In the absence o neurological def cit, the presence o PNS can be ascertained. An active neurodynamic screening test or the ulnar nerve is carried out f rst (Fig. 5.18) and a positive test would be indi cated by limitation o movement or reproduction o symptoms (H all & Elvey 2011). Following this, i the ulnar nerve neurodynamic test (Fig. 5.19) reproduces the patient’s symptoms (in the absence o such signs or the median and radial nerve) and the ulnar nerve is maximally hyperalgesic on palpation along its course (see Fig. 5.30), at points immediately distal and proximal to the cubital tunnel, sensitization o the ulnar nerve can be conf rmed. A recent study evaluated 70 consecutive patients with cubital tunnel syndrome, who had clinical ea tures o ulnar neuropathy at the elbow (Svernlov et al. 2009). All had medial elbow/ orearm pain and medial hand paraesthesia, a positive Tinel’s sign at the cubital tunnel, cubital tunnel hyperalgesia and a subjective eeling o weakness o the hand. Ulnar nerve motor and sensory conduction studies were normal in 76%, indicating no evidence o CN. This study’s f ndings highlight the low requency o CN, 2 79
C H AP TE R 5
Manag e me nt o f e lbo w dis o rde rs
Fig ure 5.18 • Ulnar nerve active screening test.
even in the presence o signif cant eatures o com pressive neuropathy. The prevalence o PNS could not be determined in this sample as neurodynamic tests were not included in that study. Interestingly, sustained nerve tensioning exercises did not provide any signif cant benef t over advice and reassurance or a night resting splint or the immediate or long term recovery (Svernlov et al. 2009). This is another example o the importance o matching neural clas sif cation to appropriate treatment (H all & Elvey 2011). The median nerve should be examined i the patient complains o anterior elbow pain with symp toms in the distribution o the median nerve. For example, a patient may complain o pain in the region o the bicipital aponeurosis with spread into the orearm, associated with tingling symptoms on the radial side o the hand when li ting heavy weights at work or in the gym or in sports associated with gripping such as archery (Rehak 2001). As with the ulnar nerve, diagnosis o PNS is based on three parts as ollows. Active neurodynamic screening or the median nerve should reproduce similar symptoms (Fig. 5.20). In addition, the neurodynamic test o the median nerve (Fig. 5.21) should also provoke similar symptoms. Finally, the median nerve should be maximally hyperalgesic proximal and distal to the pronator tunnel. In this case it is clear that PNS o the median nerve is a signif cant contributing actor to the elbow problem. The most likely site or the origin o the sensitization is the pronator tunnel. It would be important in this example to examine conductivity o the median nerve, through the neu rological examination, to rule out CN. Tinel’s test at the pronator tunnel might also be help ul in 280
Fig ure 5.19 • Ulnar nerve test.
localizing the problem. In cases o orearm pain and distal symptoms such as paraesthesia, it would be important to examine the cervical spine and carpal tunnel, in order to rule out cervical radiculopathy and carpal tunnel syndrome. The radial nerve should be examined i the patient complains o lateral elbow pain with symp toms in the distribution o the radial nerve. For example, a patient may complain o lateral elbow pain, radiating distally rom the lateral epicondyle, during extended computer keyboard use. Again CN must be di erentiated rom PNS or musculoskeletal pain by the neurological examination and tests or PNS. For PNS, active neurodynamic screening or the radial nerve must reproduce similar symptoms (Fig. 5.22). In addition, the neurodynamic test o the radial nerve (Fig. 5.23) must also provoke con cordant symptoms and will be limited in range. Finally, the radial nerve and its distal branches must be maximally hyperalgesic immediately proximal and distal to the elbow. I this is ound to be the case, then it is clear that sensitization o the radial nerve is a dominant eature o the condition. Some degree o radial nerve sensitization, evidenced by the radial nerve neurodynamic test, is a common f nding in people with lateral elbow pain (Berglund et al. 2008, Buzzi & Moskowitz 2005, Waugh et al. 2004, Yaxley & Jull 1993). Berglund et al. (2008) reported that in 58% o their sample with lateral elbow pain, orearm pain was reproduced during the radial nerve neurodynamic test. In addition,
P h ys ic a l e xa m in a tio n : th e e lb o w c o m p le x
Fig ure 5.22 • Radial nerve active screening. Fig ure 5.20 • Median nerve active screening.
A
Fig ure 5.23 • Radial nerve test.
B
Fig ure 5.21 • Median nerve test: A ULNPT 1; B ULNPT 2a.
approximately 50% o their sample reported hyper algesic responses to nerve trunk palpation. The radial nerve divides into two branches at the elbow (Standring 2008): the radial nerve superf cial branch and the posterior interosseous
nerve. For the two branches, f ve sites o com pression have been described, although these comprise only 2% o all upper limb compressive neuropathies (H ariri & McAdams 2010). Conf rmation o a radial nerve compression neuropathy is di f cult because o the similarity with lateral epicondylalgia, and the lack o clinical discerning eatures (Van H o wegen et al. 2010). For instance, the radial nerve sensory branch has no motor supply, and the posterior interosseous nerve no sensory supply, thus limiting discerning eatures o neurological def cit. Rosenbaum (1999) reviewed the evidence or radial tunnel syndrome and ound only seven o 534 cases had objective evidence o neurological conduction loss. Furthermore, the presence o nerve compression does not usually cause pain (Zusman 2008) and radial nerve com pression has been noted on dissection o cadavers, 281
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Manag e me nt o f e lbo w dis o rde rs
where there was no history o arm symptoms be ore death (Rath et al. 1993). H ence the poten tial or lateral elbow pain to arise rom a CN disorder o the radial nerve is extremely uncommon.
Pas s ive movements (joints ) The elbow complex consists o the humeroulnar, radiohumeral and radioulnar/ radioannular joints (Fig. 5.24). Any o these joints can be a source o elbow pain. Di erential examination o each joint is an important skill: • I the elbow is held 10° short o ull extension, there is an amplitude o abduction and adduction movement. During this abduction/ adduction movement, the olecranon process swings rom side to side in the olecranon ossa, the head o the radius being compressed and distracted rom the capitulum as the radius moves cephalad and caudad in the superior radioulnar joint (Fig. 5.25). The clinician should be aware o the potential or excessive joint laxity during these tests, which may be associated with medial and lateral collateral ligament damage (Ellenbecker et al. 2010a). • Also note that when the elbow joint is in extension and overpressure is added to supination and pronation, the olecranon process rotates in the olecranon ossa (Fig. 5.26).
Radiohumeral
Radioannular
Humeroulnar (Coranoid olecranon) Superior radioulnar
Fig ure 5.24 • J oints of the elbow complex. 282
• When the elbow is in ull exion there is also an additional degree o abduction and adduction movement. • When the wrist is ulnar deviated the radial head moves caudad; during radial deviation it moves cephalad. It is also important to produce movement in any one o the three joints without producing movement in the other. Testing movement o one bone on the other (e.g. radius on ulna) must be done by the physiotherapist’s f ngers and thumbs. When move ments are tested, the site o the pain elt by the patient is a guide to determining the joint(s) at ault. Examination o exion, extension, pronation and supination alone is insu f cient to determine the nor mality or otherwise o the elbow joints. Full use o accessory and joint play movements must be examined in detail i important comparable signs are not to be missed. It is important to assess the range o lateral movement o the elbow when it is held a ew degrees rom the extended position. Extension in adduction and extension in abduc tion are also important movements o the elbow to examine, as is exion in both abduction and adduction. Figure 5.27 represents the degree o adduction and abduction possible in ull extension (line X2, Y2), 10° o exion (line X1, Y1 ) and all points in between. There is a greater degree o adduction/ abduction in 10° o exion than in ull extension o the elbow. I the elbow, f rmly held in adduction, is moved rom extension through 10° o exion, that is rom X2 to X1, it will be elt that the movement is not a straight line but has a curve near the limit o extension. The exion movement in abduction rom Y2 to Y1 also ollows a slight curve though it is less marked. The pro cedures adopted to examine and treat these move ments are the techniques o extension/ adduction and extension/ abduction. I a patient subconsciously demonstrates a through range pain ul disorder with elbow prona tion and supination, the therapist should be alert to the possibility o the radioulnar joint being the problem. As well as pronation and supination, the superior radioulnar joint has passive accessory move ments o the head o the radius on the ulna: these posteroanterior and anteroposterior movements can be per ormed with the orearm in any degree o elbow pronation or supination, exion or extension. Longitudinal movements cephalad and caudad o
A
B
Fig ure 5.25 • Elbow joint: A abduction, humeroulnar approximation and olecranon abduction in olecranon fossa; B adduction, humeroulnar distraction and olecranon adduction in olecranon fossa.
A
B
Fig ure 5.26 • Elbow joint: A supination of olecranon process in olecranon fossa; B pronation of olecranon process in olecranon fossa.
C H AP TE R 5
Manag e me nt o f e lbo w dis o rde rs Central longitudinal axial line X2
Full extension
Y2
Full extension
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
O
O
O
O
O
O
n i t c u d
O
A
A
d
O
b
d
u
c
t
i
o
O
o
n
O
O
O
O
O
O
O
O
10
O
X1
O
10 Flexion from full extension O
4
O
Y1 3
O
2 1 4 Adduction available O
O
O
1
O
2 3 4 Abduction available O
O
O
10
O
4
O
10 Flexion from full extension O
Fig ure 5.27 • Range of elbow abduction/adduction in the last 10° of elbow extension (only approximate degrees used) viewed from the anterior aspect of the wrist in the anatomical position. The complete line represents the path traversed by the wrist during passive extension (a) with the elbow pressured into adduction (X1 X2 ) and (b) with the elbow pressured into abduction (Y1 Y2 ). The arrowed circular areas represent the scouring movements (E/Ad at X2 ; E/Ab at Y2 ) used in examination and treatment.
the radius on the ulna are the two remaining acces sory movements, though they have limited practical application. All o these movements can be per ormed with or without compression o the head o the radius against the ulna (Box 5.4). I the patient has pain within the elbow pos teriorly and this is only reproduced with extension overpressure, or with f rm overpressure to supina tion or pronation, this could be due to swinging o the olecranon process in the ossa. Such pain may be due to an abnormal ‘tracking’ o the ole cranon in the trochlea ossa, similarly to the patella maltracking on the emur in patello emoral pain syndrome. In such cases the olecranon should be examined with thumb pressure against the ole cranon process in the neutral or pronation/ supination positions. In addition MWM (see Figs 5.56 and 5.57) using an olecranon tilting move ment (rotation around the long axis o the ulna) can also be explored during the provocative active movement. 284
The radiohumeral joint can be pain ul in prona tion, supination and exion/ extension. To the pain ul movement (see Fig. 5.10, exion 90°) should be applied a compressive orce through the patient’s hand so as to compress the head o radius against the capitulum. To localize the movement as much as possible to the radiohumeral joint the pressure should be transmitted through the patient’s thenar eminence with the wrist deviated radially, directing the orce through the radius. The compression tech nique should be per ormed through as large a range o elbow exion to extension or pronation to supina tion (in di erent positions o exion/ extension) as is possible.
Mobilization with movement (MWM) To evaluate the potential or MWM in therapy or elbow disorders requires two actors (Vicenzino et al. 2011). The f rst is to identi y a comparable
Exa m in a tio n a n d tre a tm e n t te c h n iq u e s : e lb o w c o m p le x
sign at the elbow or a client specif c outcome measure, which might be a limitation o active movement or pain due to isometric muscle contrac tion ( or example making a f st). The second is to evaluate accessory movements at the elbow to isolate a pain ree glide direction. Typically, the glide ound to be e ective is in a medial or lateral direc tion (Vicenzino et al. 2011). The clinician then applies the pain ree glide while asking the patient to per orm the comparable sign. A signif cant improvement in pain ree movement or muscle con traction orce indicates the potential or MWM in therapy. In the Mulligan Concept, the glide component o MWM is graded according to the tolerance o the patient and the e ect the glide has on the compa rable sign (Mulligan 2010), rather than the I–V system used in the Maitland Concept. I gentler orce does not improve the comparable sign then greater orce is applied or the technique is altered in some way until improvement is achieved. For example, a substantial level o orce, at least 66% o maximum, is required to adequately change lateral elbow pain associated with gripping (McLean et al. 2002). A signif cant increase in the grip orce as a result o MWM indicates the potential or treat ment. Vicenzino et al. (2008) ound one o the uni variate predictors or success or a MWM was at least a 25% increase in pain ree grip strength ol lowing a MWM.
Di erentiation tes ts When supination or pronation provokes the patient’s symptoms and it is necessary to di erentiate between the radiohumeral and the superior radioul nar joints as the source, the rotary movement is per ormed with the wrist held in ulnar deviation (to lessen the stress on the radiohumeral joint) and then repeated with the wrist in radial deviation. Di erent positions o exion/ extension may also help to make the di erentiation. Also, i there is intra articular involvement o the superior radioulnar joint, adding medially directed pressure against the proximal end o the radius during the rotary movement will increase the pain response (see Fig. 5.13). When exion or extension provokes the patient’s symptoms, the position (o exion or extension and ulnar deviation) should be held while the head o the radius is moved back and orth (AP–PA). I the disorder lies in the humeroulnar articulation,
movement o the radius will not make any di er ence to the pain response.
Examinatio n and tre atme nt te c hnique s : e lbo w c o mple x Neurological examination Neurological examination is an important compo nent o the evaluation o elbow region neural tissue pain disorders, particularly CN. Such testing should incorporate both subjective inquiry and physical tests o nerve conductivity. The subjective examination must clearly identi y the specif c type and area o symptoms, including paraesthesias and sensory loss. These areas can then be compared with typical dermatomal and cutane ous sensory innervation maps. The clinician should not rely purely on dermatomal charts when deter mining the segmental origin o pain because these charts are not the ideal diagnostic re erence (Bove et al. 2005), given the signif cant overlap o innerva tion rom adjacent nerve roots and the great variabil ity among individuals (Slipman et al. 1998, Wol et al. 2001). Physical neurologic examination procedures include tests or sensation (light touch, pin prick, two point discrimination and vibration), tendon re exes and muscle strength. The pattern o sensa tion loss, re ex change and specif c muscle weak ness enables the clinician to determine the location o nerve injury. For example, compression neu ropathy o the ulnar nerve at the elbow would be indicated by weakness o exor digitorum pro undus and abductor digitiminimi, together with sensory loss o the tip o the f th f nger (Jepsen et al. 2006, Jepsen & Thomsen 2006).The pattern o neurological def cit would be di erent or a C8 nerve root disorder, although pain may be in a similar distribution. Although some studies have investigated the reli ability and diagnostic validity o the neurologic examination (Jepsen et al. 2006, Jepsen & Thomsen 2006, Schmid et al. 2009), its value has been ques tioned (Viikari Juntura 1987, Viikari Juntura et al. 1989, Wainner et al. 2003, Wainner & G ill 2000). Despite good levels o reliability having been dem onstrated or individual items o the neurological examination in the upper limb (Jepsen et al. 2006, Jepsen & Thomsen 2006, Schmid et al. 2009), 285
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greatest conf dence in the neurological status is achieved by incorporating the subjective history together with the physical examination f ndings (Viikari Juntura et al. 1989, Vroomen et al. 2000). Wainner et al. 2003 investigated the diagnostic accuracy o a range o cervical physical tests (includ ing aspects o the neurological examination) to iden ti y cervical radiculopathy and reported that a cluster o physical tests was more use ul than was any single test item. Similarly it has been shown, based on the complete neurological examination, that there is good agreement between examiners in identi ying the location o a specif c peripheral nerve disorder in the upper limb (Jepsen et al. 2006, Jepsen & Thomsen 2006).
Nerve palpation Nerve trunks can be selectively palpated to deter mine a heightened state o mechanosensitivity. While there is evidence that such palpation is reli able, in both the upper limb (Jepsen et al. 2006, Jepsen & Thomsen 2006, Schmid et al. 2009) and lower limb (Walsh & H all 2009), nerve palpation requires a sound knowledge o anatomy to be certain o palpation accuracy. In the elbow region the three major upper limb nerve trunks are accessible and can be palpated as distinct entities. Neural tissues o the uninvolved or least a ected side are palpated f rst to allow the patient to make a comparison. G ently and pre cisely, gradually increasing pressure is applied until deemed su f cient to complete the examination. In some patients the elbow may be hyperalgesic to the point that a specif c tissue diagnosis may not be possible. In such a case the neural system should be palpated more proximally, perhaps in the upper arm or axilla.
Me d ia n ne rve (Fig. 5.28) • Patient starting position: Supine with the orearm supinated and the elbow exed to 90°. • Therapist starting position: Standing by the patient’s elbow acing the patient’s head. • The median nerve lies with the brachial artery, immediately medial to the biceps tendon. Anterior elbow so t tissue tension is reduced in exion, allowing greater ability to isolate the structure o the median nerve. 286
Ra d ia l ne rve (Fig. 5.29) • Patient starting position: Supine with the shoulder medially rotated and elbow exed to 90°. • Therapist starting position: Standing by the patient’s elbow acing the patient’s head. The radial nerve can be palpated on the lateral side o the biceps tendon, proximal to the elbow, prior to bi urcation into the radial sensory branch and posterior interosseous nerve. At mid humeral level, the radial nerve can be palpated as it passes through the lateral intramuscular septum, a ew centimetres below the deltoid in the spiral groove (Fig. 5.29). The radial sensory branch and posterior interosseous nerve are most readily palpated distal to the elbow. The posterior interosseous nerve lies deep and is best palpated rom the lateral side, displacing the lateral extensor muscle mass below the elbow, to identi y the nerve on the anterolateral aspect o the neck o the radius.
Ulna r ne rve (Fig. 5.30) • Patient starting position: Supine with the orearm supinated and elbow exed to 90°. • Therapist starting position: Standing by the patient’s elbow acing the patient’s head. The ulnar nerve is palpated posterior to the medial epicondyle, or immediately distal to the elbow on the medial side o the ulna. Access to the nerve is increased when the elbow is exed.
Pas s ive movements Exte ns ion/a d d uc tion (Fig. 5.31) • Direction: Elbow is exed 10° rom ull extension and held in adduction. During the f rst ew degrees o extension held in adduction the orearm moves parallel to the elbow sagittal plane. A point is reached where the elbow abducts and adducts again (similar to the mound o the shoulder quadrant). There is no locking position but the eel is similar to that o the shoulder as the point o abduction on the roll over is reached (see Fig. 5.27) and the extension in adduction continues to X1. O nce the point o roll over is passed the glenohumeral joint will automatically medially rotate i the adduction pressure is maintained su f ciently.
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Fig ure 5.28 • Median nerve palpation.
Fig ure 5.29 • Radial nerve palpation.
Fig ure 5.30 • Ulnar nerve palpation.
• Symbol: Elbow E/ Ad. • Patient starting position: Supine, lying ar enough rom the edge o the couch or the patient’s elbow to lie just beyond the edge when the arm is abducted 30°. • Therapist starting position: Standing by the patient’s right shoulder acing the patient’s eet.
Localization of forces (position of therapist’s hands)
• The thumb o the le t hand extends around the • • • •
• The le t orearm rests in ront o and just medial to the patient’s shoulder. • The f ngers o the le t hand support the patient’s elbow posteriorly rom the medial side.
• •
medial epicondylar ridge o the humerus to reach the ront o the patient’s elbow. The back o the le t hand rests against the sur ace o the couch at its edge. The le t hand medially, the f ngers and couch posteriorly, the thumb anteriorly and the le t thigh laterally, f rmly f x the patient’s elbow. The right hand grasps the patient’s supinated right wrist. The right thumb is placed over the anterior sur ace o the wrist. The f ngers are placed over the dorsum o the wrist. The supination is not held strongly at the limit o the range. 287
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• I the limitation is pain ul the adduction pressure can be eased as the pain and limitation are approached. • The arc o movement can be per ormed when extending towards the limit or adducting towards it.
Uses • The extension/ adduction movement is only •
Fig ure 5.31 • Elbow joint: extension/adduction.
• • The patient’s glenohumeral joint is medially rotated to stabilize the elbow more easily during the adduction. There ore the abduction counterpressure a orded by the therapist’s le t hand is being assisted by the edge o the couch.
Application of forces by therapist (method)
• •
• The part o the extension/ adduction range which has been lost should be sought; the examination or treatment is directed at this particular part o the range. Lateral collateral ligament damage, and subsequent laxity, would lead to excessive range with a so t end eel and would be a contraindication to the use o this technique in management. • The limited movement is approached: (1) by an adduction or extension/ adduction movement or (2) by a scouring circular movement (see Fig. 5.27): 1. per ormed as a grade III or IV: III – the pressure maintaining adduction is almost completely released to allow the joint to relax to the position almost midway between abduction and adduction be ore oscillating back to the adduction position; IV – the pressure maintaining adduction limits the oscillation to a small amplitude; or 2. per ormed by maintaining the adduction pressure while exing and extending the elbow across the limitation. 288
•
used in the treatment when grade III or IV is required. When the elbow joint is the source o minor symptoms and its movements appear to be normal, this accessory movement or functional corner position may be diminished and pain ul. In treatment, the movement o extension/ adduction can be scoured in much the same way as was described or the glenohumeral joint. The scouring movement is represented at X2 by the arrowed circular arcs in Figure 5.27. O ten ound to be pain ul and restricted in patients with chronic lateral epicondylalgia (H yland et al. 1990). Particularly valuable or minor but troublesome disorders o the humeroulnar and radiohumeral joints. A test which can be used when the elbow needs to be excluded as a source o symptoms.
Exte ns ion/a b d uc tion (Fig. 5.32) • Direction: Extension/ abduction should be checked rom the ully extended position through the f rst 10° o exion. As with extension/ adduction, a point is reached during this range o exion where the arm must be allowed to adduct i the exion movement is to be continued. Beyond the point o maximum abduction the arm moves laterally again, but this lateral movement will be a lateral rotation o the glenohumeral joint rather than an abduction o the elbow. There is not the same eel o a locking position with this movement as there is with adduction but it is still obvious that the movement rom Y1 to Y2 in Figure 5.27 is not a straight line but is slightly curved. Any loss o the smooth contour o the curve can be appreciated and can be treated by movement into this position.
Exa m in a tio n a n d tre a tm e n t te c h n iq u e s : e lb o w c o m p le x
• The f ngers o the right hand spread over the • • •
•
ront o the patient’s wrist to hold the patient’s supinated wrist rom the medial side. The right thumb is placed over the posterior sur ace o the wrist. The supinated wrist is not held strongly at the limit o the range. The patient’s glenohumeral joint is held in slight lateral rotation so that the abduction movement can be directed against the therapist’s thigh which then acts as a ulcrum. The patient’s elbow must be ully f xed by the therapist’s hand against a very f rm ulcrum.
Application of forces by therapist (method) • The part o the extension/ abduction range Fig ure 5.32 • Elbow joint: extension/abduction.
• Symbol: Elbow E/ Ab. • Patient starting position: Supine, lying ar enough rom the edge o the couch or the patient’s elbow to lie just beyond the edge when the arm is abducted 30°. • Therapist starting position: Standing by the patient’s right shoulder acing the patient’s eet.
Localization of forces (position of therapist’s hands) • The le t orearm rests in ront o and just • • • •
•
medial to the patient’s shoulder. The f ngers o the le t hand support the patient’s elbow posteriorly rom the medial side. The thumb o the le t hand extends around the medial epicondylar ridge o the humerus to reach the ront o the patient’s elbow. The back o the le t hand rests against the sur ace o the couch at its edge. The le t hand medially, the f ngers and couch posteriorly, the thumb anteriorly and the le t thigh laterally, f rmly f x the patient’s elbow. The right hand grasps the patient’s supinated right wrist.
which has been lost should be sought; the examination or treatment is directed at this particular part o the range. • The limited movement is approached: (1) by an abduction or extension/ abduction movement or (2) by a scouring circular movement (see Fig. 5.27): 1. per ormed as a grade III or IV: III – the pressure maintaining the abduction is almost completely released to allow the joint to relax to the position almost midway between adduction and abduction be ore oscillating back to the abduction position; IV – the pressure maintaining the abduction limits the oscillation to a small amplitude; or 2. per ormed by maintaining the abduction pressure while exing and extending the elbow across the limitation.
• I the limitation is pain ul the abduction pressure can be eased as the pain and limitation are approached. • The arc o movement can be per ormed when extending towards the limit or abducting towards it.
Uses • The extension/ abduction movement is only used in the treatment when grade III or IV is required. Medial collateral ligament damage, and subsequent laxity, would lead to excessive range with a so t end eel and would be a contraindication to the use o this technique in management. 289
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• When the elbow joint is the source o minor symptoms and its movements appear to be normal, this accessory movement or functional corner position may be diminished and pain ul. • In treatment, the movement o extension/ abduction can be scoured in much the same way as was described or the glenohumeral joint. The scouring movement is represented at Y2 by the arrowed circular arc in Figure 5.27. • Particularly valuable or minor but troublesome disorders o the humeroulnar and radiohumeral joints. • A test which can be used when the elbow needs to be excluded as a source o symptoms.
Fle xion/a d d uc tion (Fig. 5.33) • Direction: Adduction movement in ull elbow exion. • Symbol: Elbow F/ Ad. • Patient starting position: Supine in the middle o the couch and the elbow ully exed and pronated. • Therapist starting position: Standing by the patient’s right hip acing the patient’s head.
Localization of forces (position of therapist’s hands) • The le t hand holds the patient’s ully pronated • • •
• •
wrist. The f ngers o the le t hand are placed over the back o the patient’s wrist. The thenar eminence and thumb are placed over the ront o the patient’s wrist. The right hand grasps f rmly around the patient’s upper arm at the junction o the middle and lower thirds rom the medial side in such a way as to hold the upper arm laterally rotated. The slack in the so t tissues o the upper arm must be taken up ully. Both orearms (therapist) are rotated opposite to each other.
Application of forces by therapist (method) • The exion/ adduction movement is per ormed entirely by the therapist’s le t hand and arm while medial rotation o the glenohumeral joint is prevented by the f rm grasp o the patient’s upper arm with the therapist’s right hand. • I medial rotation is not prevented the adduction strain at the patient’s elbow will be lost. • The treatment movement can be per ormed as a large amplitude oscillation through 10–15° (III) or a small amplitude movement through 3–4° (IV).
Uses • Flexion/ adduction is used when a grade III or IV movement is required. • Minor elbow symptoms, particularly o the humeroulnar and radiohumeral joints. • When the elbow needs to be excluded as a source o symptoms.
Fle xion/a b d uc tion (Fig. 5.34) • Direction: Abduction movement in ull elbow
Fig ure 5.33 • Elbow joint: exion/adduction. 290
exion. • Symbol: Elbow F/ Ab. • Patient starting position: Supine, lying in the middle o the couch with the elbow ully exed and supinated.
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and then displacing the patient’s wrist laterally with an abduction movement o the elbow, while applying an equal counterpressure with the le t hand to prevent any lateral rotation o the glenohumeral joint. • I this counterpressure is not applied adequately the sideways movement o the patient’s wrist will consist o lateral rotation o the glenohumeral joint without there being any abduction o the elbow.
Uses • Flexion/ abduction is used when a grade III or IV is required. • Minor elbow symptoms particularly o the humeroulnar or radiohumeral joints. • When the elbow needs to be excluded as a source o symptoms.
Exte ns ion (Fig. 5.35) Fig ure 5.34 • Elbow joint: exion/abduction.
• Direction: Elbow extension movement. • Symbol: Elbow E.
Grade II • Therapist starting position: Standing by the patient’s right hip acing the patient’s head.
Localization of forces (position of therapist’s hands) • The right hand grasps the patient’s supinated • • •
• •
wrist rom the medial side. The f ngers spread across the ront o the wrist. The thumb is placed across the back o the patient’s wrist. The le t hand grasps the patient’s upper arm at the junction o the middle and lower thirds (with the patient’s glenohumeral joint in medial rotation) in such a way as to prevent lateral rotation o the glenohumeral joint. The slack in the so t tissues o the upper arm must be taken up ully. Both orearms (therapist’s) are rotated opposite each other.
Application of forces by therapist (method) • The exion/ abduction movement is produced by the therapist ully exing the patient’s elbow
• Patient starting position: Supine, lying in the middle o the couch. • Therapist starting position: Standing by the patient’s right hip acing the patient’s head with the right knee on the couch.
Localization of forces (position of therapist’s hands) • The le t hand supports laterally around the • • • • • • •
patient’s right arm just above the elbow. The thumb is placed anteriorly. The f ngers spread posteriorly. The right hand grasps the palm o the patient’s supinated hand. The right thumb reaches between the patient’s thumb and index f nger to the back o the patient’s hand. The medial three f ngers reach around the patient’s hyperthenar eminence to the back o his hand. The index f nger points proximally over the anterior aspect o the patient’s wrist. Moving close to the elbow the thigh is used as a stop at the required angle. 291
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B
A
D
C
Fig ure 5.35 • Elbow joint: A extension, grade II; B, C extension grade III/IV; D palpation in olecranon fossa in extension.
292
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E
F
Fig ure 5.35 • c o nt’d E, F further examination of the olecranon.
Application of forces by therapist (method)
Grade III (IV)
• The oscillatory movement is per ormed entirely
• Patient starting position: Supine lying with the
by the therapist’s right arm while the therapist’s le t hand acts as a com ortable support around the patient’s elbow. • The grasp o the patient’s right wrist is such that relaxation in this area and throughout the arm is encouraged. • The amplitude o movement varies but is usually approximately 20–30° and is per ormed slowly and smoothly.
arm abducted approximately 15° so that the wrist is clear o the edge o the couch. • Therapist starting position: Standing by the patient’s right shoulder acing the patient’s eet.
Uses • Clinical groups 1 and 3b. • Recent injury or acute episode o OA or RA. • Very pain ul elbow conditions where the radiohumeral or humeroulnar joint is involved.
Localization of forces (position of therapist’s hands) • The le t hand supports under the patient’s elbow rom the medial side. • The le t orearm holds the patient’s shoulder down. • The right hand grasps the patient’s partially supinated wrist laterally. • The thenar eminence and thumb point distally across the ront o the patient’s wrist. 293
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• The f ngers hold across the back o the patient’s wrist and hand.
Application of forces by therapist (method) • The oscillatory movement is per ormed entirely by the therapist’s right arm. The patient’s right hand is stabilized by the grasp o the wrist. • The amplitude o the elbow movement is approximately 20–30° (grade III). • For through range pain the movement is per ormed slowly and smoothly. • For chronic end o range pain and sti ness the movement is per ormed as a staccato icking movement.
Variations in the application of forces: grade III (IV) • Therapist starting position: Standing by the
involving sti and sti / pain ul humeroulnar or radiohumeral joints. • Patients with elbow disorders in clinical groups 2 and 3b. • The alternative method is best used or the last 30° o extension when the patient needs to relax more.
Fle xion (Fig. 5.36) • Direction: Elbow exion movement. • Symbol: Elbow F. • Patient starting position: Supine, lying in the middle o the couch.
Grade II • Therapist starting position: Standing by the patient’s right shoulder acing the patient’s eet.
patient’s right hip acing the patient’s head.
Localization of forces (position of therapist’s hands) • The patient’s right arm is li ted f rst so that it can be held against the therapist’s right side. • Both hands hold around the elbow. • The thumbs are placed anteriorly to the joint and the f ngers o both hands overlap posteriorly.
Application of forces by therapist (method) • Feel or the so t tissue movement between the olecranon and the margins o the olecranon ossa during extension. This so t tissue palpation should be compared with the normal elbow. • Normally the f ngertips should easily f t into the space between the process and the ossa margins. The eeling should be that o clean bony margins. • Palpation o these margins can also be carried out with the patient prone, lying with the upper arm supported on the couch and the hand and orearm hanging down to the oor. • Thumb pressure or the heel o the hand can then be applied to the olecranon medially, laterally, caudally and with compression (Fig. 5.35 E and F).
Uses grade III (IV) • Limitation o elbow extension due to injury, resolving episodes o OA or RA or racture 294
A
B
Fig ure 5.36 • Elbow joint: A exion grade II; B exion grades III and IV.
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Localization of forces (position of therapist’s hands) • The le t orearm crosses the patient’s right
• • • •
upper arm so that the le t hand can support under the patient’s elbow rom the medial side. The right hand grasps the patient’s partially supinated wrist rom the lateral side. The f ngers lie across the back o the patient’s hand. The thumb lies between the patient’s thumb and index f nger into the palm. The stop is provided by the le t orearm in contact with the patient’s right wrist rom in ront as the elbow is exed to the required degree.
• G rade III movements are per ormed as large amplitude movements o 10–30° into sti ness. • G rade IV movements are per ormed as small amplitude movements o 3–4° into sti ness.
Flexion with longitudinal movement caudad (Fig. 5.37) • Direction: Elbow exion combined with a longitudinal movement caudad. • Symbol: F/ caud. • Patient starting position: Supine, lying in the middle o the couch. • Therapist starting position: Standing by the patient’s right hip acing the patient’s head.
Localization of forces (position of therapist’s hands)
Application of forces by therapist (method)
• The right hand exes the patient’s elbow
• The oscillatory movement, per ormed by the
to 90°. • The right hand grasps round the medial aspect o the patient’s supinated wrist. • The f ngers spread across the ront o the wrist.
therapist’s right arm, is taken back and orth through 20–30° slowly and smoothly up to the stop provided by the le t orearm. • As the range improves the orearm can be lowered.
Grade III and IV (almost full range) • Therapist starting position: Standing by the patient’s right side distal to the elbow, acing the patient’s head.
Localization of forces (position of therapist’s hands) • The le t hand supports the patient’s right upper • • • • •
arm just above the elbow. The right hand holds the back o the patient’s right hand. The thumb o the right hand passes through the patient’s f rst interosseous space. The medial three f ngers spread medially around the patient’s f th metacarpal. The index f nger extends distally along the back o the hand. The patient’s partially supinated elbow is exed.
Application of forces by therapist (method) • The oscillatory movement is produced entirely by moving the patient’s right arm while the therapist’s le t hand acts as a support under the elbow.
Fig ure 5.37 • Elbow joint: exion with longitudinal movement caudad. 295
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• The thumb is placed across the back o the wrist. • The supinated le t orearm just proximal to the wrist is placed in the ‘crook’ o the patient’s elbow. • The exion o the patient’s elbow is then continued until the le t wrist is squeezed f rmly between the patient’s orearm and upper arm.
Application of forces by therapist (method) • The small oscillatory movements are produced by the therapist’s right arm. • Care is needed to maintain the therapist’s wedged wrist in a constant proximity to the patient’s elbow because the tendency will be or it to be squeezed out. • A wrong degree o supination orming the wedge will make the position uncom ortable or the patient.
Uses (all exion techniques) • Clinical groups 1, 2, 3a and 3b adapted to the desired e ect. • Pain and/ or sti ness ollowing injury or racture a ecting the humeroulnar and radiohumeral joints in particular. • Flexion with longitudinal caudad may be o value or disorders where symptoms are minor and not obviously detected on routine testing.
Fig ure 5.38 • Elbow joint: longitudinal movement caudad (90° exion).
• The posterior aspect o the lower orearm rests on the therapist’s right shoulder.
Application of forces by therapist (method) • The so t tissue slack around the humerus and orearm must be taken up be ore alternating pressures are applied against the orearm to produce the distraction movement. • The movement can be combined with an increase in elbow exion. • The le t hand can be positioned so as to move: (1) both the radius and ulna; (2) the radius alone; (3) the ulna alone.
Longitud ina l move me nt c a ud a d (e lb ow in 90° e xion) (Fig. 5.38)
Uses
• Direction: Longitudinal movement caudad in
2, 3b). • Sti ness and pain o this accessory movement at the limit o or in exion.
90° o elbow exion, that is in line with the humerus. • Symbol: caud. • Patient starting position: Supine, lying in the middle o the couch with the elbow exed to 90° or to the limit o the available range. • Therapist starting position: Standing by the patient’s right thigh acing the patient’s head.
Localization of forces (position of therapist’s hands) • The right hand grasps the proximal anterior aspect o the patient’s supinated right orearm. • The palm o the le t hand f xes the humerus to the table, close to the elbow joint. 296
• When symptoms are minimal (clinical groups
Note: it is also possible to per orm a longitudinal caudad movement on the ulna and radius using a manual therapy belt (Fig. 5.39). In this case the humerus is f xed by the therapist’s le t hand, while the mobilizing orce is created by the therapist drawing the pelvis posteriorly.
Sup ina tion (Figs 5.40 and 5.41) • Direction: Supination o the orearm and elbow. • Symbol: Sup. • Patient starting position: Supine, lying in the middle o the couch with the elbow exed to 90°.
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• The lateral sur ace o the distal phalanx o the • • • • •
index f nger holds the distal end o the radius posteriorly. The pad o the thumb holds anteriorly. The right hand holds the distal end o the ulna. The thumb and thenar eminence point distally over the posterior sur ace o the ulna. The f ngers hold the ulna anteriorly. The orearms are directed opposite each other at right angles to the coronal plane o the patient’s ully supinated wrist.
Application of forces by therapist (method) Fig ure 5.39 • Longitudinal caudad radius and ulna using belt.
• Therapist starting position: Standing by the patient’s right side beyond the exed elbow, acing the patient’s head.
Gra d e s III a nd IV Localization of forces (position of therapist’s hands) • The le t hand supports under the patient’s elbow. • The right hand grasps the patient’s supinated wrist rom the medial side. • The f ngers spread across the ront o the wrist and carpus. • The thumb holds across the back o the wrist and carpus.
Application of forces by therapist (method) G r a d es III a nd IV • In addition to the above, the patient’s elbow must be supported medially by the therapist to prevent any glenohumeral adduction.
G r a d e IV− • Therapist starting position: Standing by the patient’s exed right elbow.
Localization of forces (position of therapist’s hands) • The le t and right hands hold the patient’s ully supinated radius and ulna respectively; the hold is ar enough distally to stabilize the hand. • The le t orearm is ully supinated.
• The therapist’s orearms are directed in the same line and the movement is produced as the patient’s orearm is supinated a urther 2–3° by a rocking action o the therapist’s pelvis and trunk through the hands to the radius and ulna and then released (IV+ to IV− then IV− to IV+). • A small amplitude o movement is there ore used. • I the elbow supination range is limited, the therapist’s body is turned to the right an appropriate amount so that the orearm direction is changed.
Uses • Mainly or a pain ul or sti superior radioulnar joint or sti ness o the olecranon which swings at the extreme o supination.
P rona tion (Figs 5.42 and 5.43) • Direction: Pronation o the orearm and elbow. • Symbol: Pron. • Patient starting position: Supine, lying in the middle o the couch with the elbow exed to 90°.
Gra d e s II, III a nd IV • Therapist starting position: Standing by the patient’s right hip acing the patient’s head.
Localization of forces (position of therapist’s hands) • The right hand supports under the patient’s exed right elbow so that the f ngers can reach the lateral sur ace. 297
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Fig ure 5.40 • Superior radioulnar joint: supination grades I–IV.
Fig ure 5.41 • Superior radioulnar joint: supination grade IV+.
Fig ure 5.42 • Superior radioulnar joint: pronation.
298
Fig ure 5.43 • Superior radioulnar joint: pronation, grade IV+.
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• The le t hand grasps the pronated orearm • • •
• •
distally. The f ngers o the le t hand extend across the dorsum o the wrist and hand to reach the carpus. The thumb extends around the anterior sur ace o the wrist and hand so that the wrist is ully stabilized. The rotary movement is per ormed by slight exion o the therapist’s glenohumeral joint combined with le t shoulder and elbow extension, thus assisting the orward movement o the therapist’s arm. This action is combined with ull exion o the therapist’s wrist and f ngers to produce pronation. The therapist’s right hand stabilizes the patient’s upper arm preventing abduction o the shoulder.
Gra d e IV− • Therapist starting position: Standing by the patient’s elbow, acing across the body, the patient’s elbow being exed to 90° and pronated.
Localization of forces (position of therapist’s hands) • The le t and right hands grasp the distal ends o • • • • • • •
the radius and ulna, respectively. The thenar eminence o the le t hand is placed against the dorsal sur ace o the radius. The thumb o the le t hand extends distally across the back o the patient’s wrist. The f ngers grasp anteriorly around the radius. The right hand, ully supinated, grasps the distal end o the ulna. The heel o the right hand and thumb point proximally against the anterior sur ace o the ulna. The f ngers grasp around the ulna to reach the posterior sur ace. The orearms are directed opposite each other.
Application of forces by therapist (method) • The therapist’s orearms are directed in the same line and the movement is produced as the patient’s orearm is pronated a urther 2–3° by a rocking action o the therapist’s pelvis and
trunk through the hands to the radius and ulna and then released (IV+ to IV−, IV− to IV+). • A small amplitude movement is there ore used. • I the elbow pronation range is limited, the therapist’s body is turned to the le t an appropriate amount so that the orearm direction is changed.
Uses • Mainly or pain ul or sti superior radioulnar joint or sti ness o the olecranon as it swings at the extreme o pronation.
Ante rop os te rior move me nt of the he a d of the ra d ius (Fig. 5.44) • Direction: Anteroposterior movement o the head o the radius in relation to the trochlea o the humerus and the ulna. • Symbol: • Patient starting position: Supine, lying in the middle o the couch. • Therapist starting position: Standing by the patient’s right side beyond the slightly exed right elbow, acing the patient’s head.
In s up ina tion Localization of forces (position of therapist’s hands) • The therapist’s right side supports the back o the patient’s supinated orearm. • The pads o the thumbs are placed over the anterior sur ace o the head o the radius. • The f ngers o the le t and right hands spread over the lateral and medial sur aces o the upper end o the patient’s orearm.
Application of forces by therapist (method) • The therapist gradually applies pressure with the thumbs so that they sink into the relaxed muscle tissue until they contact the head o the radius. • The oscillatory movement is produced by the therapist’s body and arms acting through the thumbs, which act like springs. • The movement must not be produced by the therapist’s thumb exors as this will be uncom ortable or the patient and the therapist will lose all eel to the movement. 299
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In p rona tion
• Therapist starting position: Standing by the patient’s right side distal to the slightly exed elbow, acing the patient’s head.
Localization of forces (position of therapist’s hands) • The right hand holds the patient’s pronated le t • • • • • •
wrist around its lateral border. The thumb o the right hand crosses the back o the patient’s wrist. The f ngers cross in ront o the patient’s wrist. The patient’s orearm is held in pronation as the anteroposterior movement tends to produce supination. The therapist’s side supports the patient’s orearm. The pad o the le t thumb is placed against the head o the radius anteriorly. The f ngers o the le t hand spread around the lateral sur ace o the patient’s orearm.
In s up ina tion Localization of forces (position of therapist’s hands) • The right hand holds the patient’s supinated • • • •
Application of forces by therapist (method) • The oscillatory movement is produced by the therapist’s le t arm acting through the stable le t thumb while the pronation o the patient’s orearm is maintained by the grip o the therapist’s right hand.
Uses • Lateral epicondylalgia where joint signs are • • • • •
evident. Pain ul loss o range o elbow exion, extension, pronation and supination due to acute injury or mechanically generated in ammation. Through range mobilization o pain and sti ness in the anteroposterior direction. Minor symptoms which can be directly reproduced in this direction. Combined with the posteroanterior direction. Most relevant or use in disorders o the radiohumeral and superior radioulnar joints.
•
right wrist rom the medial side. The right thumb is placed across the ront o the patient’s wrist. The f ngers spread across the back o the wrist. The pad o the le t thumb, pointing distally, is placed against the dorsal sur ace o the head o the radius. The f ngers o the le t hand are placed against the ront o the distal end o the patient’s upper arm to provide counterpressure or the movement. The patient’s wrist is stabilized in supination as the movement tends to produce pronation.
Application of forces by therapist (method) • The movement is produced by small adduction movements o the therapist’s le t shoulder combined with slight orearm supination (therapist’s) to exert pressure against the head o the radius with the le t thumb. • The oscillatory movement should not be produced by the therapist’s thumb exors as the eeling o movement will be lost and the pressure will be uncom ortable to the patient and the operator.
In p rona tion • The same localization of forces and application of forces are applied with the exception that the patient’s orearm and wrist are held in pronation.
P os te roa nte rior move me nt of the he a d of the ra d ius (Fig. 5.45)
Uses
• Direction: Posteroanterior movement o the
• As a grade III or IV or osteoarthritis (non
head o the radius in relation to the trochlea o the humerus and the ulna. • Symbol: • Patient starting position: Supine, lying in the middle o the couch with the elbow exed at 30° and either ully supinated or ully pronated. 300
severe or irritable) causing sti ness and pain or sti ness in disordered radiohumeral or superior radioulnar joints. • Where pain ul joint signs are causing pain inhibition o the wrist and orearm extensor muscles.
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• Minor symptoms which can be directly
• As the therapist pulls with the right hand the
reproduced in this movement direction. • Combined with the anteroposterior direction. • Most relevant or use in the radiohumeral and superior radioulnar joints.
therapist’s le t hand sinks into the patient’s exor muscle tissue to hold the upper arm f rmly. • Slack must be taken up at the wrist. • Small oscillatory movements can be per ormed by a pulling action o the therapist’s right arm counteracted by a stabilizing pressure through the therapist’s le t hand. • The movement can be enhanced by adding ulnar deviation in rhythm with the pulling action.
Longitud ina l move me nt c a ud a d (ra d ioulna r) (Fig. 5.46) • Direction: Longitudinal movement caudad o the radius in relation to the humerus and ulna in the line o the orearm (in any position o elbow exion, extension, pronation, supination; examine in the mid position o all these movements initially or best e ects). • Symbol: caud. • Patient starting position: Supine lying in the middle o the couch with the elbow mid way between exion, extension, pronation and supination. • Therapist starting position: Standing by zthe patient’s right side just beyond the elbow.
Localization of forces (position of therapist’s hands) • The therapist’s right side has the patient’s right • • • • • • • •
orearm resting against it. The le t hand holds across the ront o the patient’s upper arm proximal to the elbow. The f ngers o the le t hand spread laterally. The thumb o the le t hand is placed medially. The web o the f rst interosseous space is the main point o contact with the patient’s upper arm. The right hand grasps the anterior sur ace o the patient’s mid supinated carpus. The thumb o the right hand grasps around the radial sur ace proximal to the base o the f th metacarpal. The middle f nger and thumb reach as ar as possible around the posterior sur ace o the carpus. The right orearm must be brought into the same line as the patient’s orearm.
Application of forces by therapist (method) • When this technique is used in treatment as a grade IV the slack o the so t tissues must be taken up f rst.
Variations in the application of forces With adjustment o the right hand position, the longitudinal caudad movement can also be produced at: 1. Both the radius and the ulna at the same time; 2. The ulna alone by grasping around the ulna with the right hand and combining the pull on the ulna with a radial deviation o the patient’s wrist to enhance the longitudinal movement; and 3. The radius alone as described above.
Uses • When this movement direction is most pain ul • • • •
and restricted. For very pain ul intra articular radiohumeral or humeroulnar disorders where this movement a ords relie o pain. To complement pain ree movement o exion, extension, pronation or supination at the elbow. As an accessory movement grade IV at the limit o sti painless pronation or supination (sti superior radioulnar joint). As a part o joint di erentiation testing at the elbow.
Mobilization with movement It is important to re emphasize that MWM are pain ree accessory movements (glides) combined with the most comparable activity or movement (Mulligan 2010). The glide component is always per ormed parallel to the treatment plane o the joint, which is a line drawn across the concave joint sur ace. I the technique is success ul, the patient will be able to achieve a substantial improvement in the 301
A
B
Fig ure 5.44 • Superior radioulnar joint: A anteroposterior movement in supination; B anteroposterior movement in pronation.
Fig ure 5.45 • Superior radioulnar joint: posteroanterior movement in supination.
Fig ure 5.46 • Superior radioulnar joint: longitudinal movement caudad.
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comparable activity or movement without pain, while the glide is maintained (Vicenzino et al. 2011). The amount o gliding orce will depend on the suc cess ul outcome o the technique. I the activity or range is improved, the technique is repeated six to 10 times be ore reassessment without the glide com ponent. I improvement in the comparable sign is maintained the technique could be used in manage ment. Three to f ve sets would be undertaken. H ome exercise should also be prescribed, mimicking the clinic technique as closely as possible, to aid patient progress. The technique would be progressed to achieve maximum range with overpressure. These principles have been reviewed (H ing et al. 2008) and apply or all the ollowing techniques.
Elb ow e xte ns ion with la te ra l glid e MWM – a s s e s s me nt (Fig. 5.47) • Direction: Elbow extension movement. • Symbol: Elbow E MWM lat glide. • Patient starting position: Supine, lying to the right side o the couch. • Therapist starting position: Standing by the patient’s right side, acing towards the patient’s head.
Localization of forces (position of therapist’s hands)
• Recent or chronic injury or episode o OA. • Very pain ul elbow conditions.
Elb ow e xte ns ion with la te ra l glid e MWM – b e lt (Fig. 5.48) • Direction: Elbow extension movement. • Symbol: Elbow E MWM belt lat glide. • Patient starting position: Supine, lying to the right side o the couch. • Therapist starting position: Standing by the patient’s right elbow, acing across the patient.
Localization of forces (position of therapist’s hand and manual therapy belt) • The elbow is positioned at the point o • • • •
extension limitation prior to the onset o pain. The le t hand contacts the extreme distal lateral aspect o the humerus to support and stabilize the upper arm in lateral rotation. The right hand grips the lower orearm to control the movement into extension. The manual therapy belt is looped around the therapist’s pelvis and the proximal end o the patient’s right orearm. The manual therapy belt is horizontal at all times.
• The elbow is positioned at the point o
Application of forces by therapist (method)
extension limitation prior to the onset o pain. • The le t hand contacts the extreme distal lateral aspect o the upper arm to support and stabilize the humerus such that the shoulder is f xed in lateral rotation. • The right hand contacts the extreme proximal medial aspect o the orearm. • The therapist’s orearms are positioned perpendicular to the patient’s upper limb.
• The therapist applies a lateral gliding orce on
Application of forces by therapist (method) • The right hand glides the proximal orearm in a lateral direction. • The le t hand applies a stabilizing counter orce in a medial direction on the distal humerus. • While maintaining the lateral glide, the patient actively extends the elbow.
the proximal orearm through the belt. • The le t hand stabilizes the distal humerus. • While the glide is maintained, the patient actively extends the elbow. • The therapist moves his pelvis to the right to account or movement o the patient’s orearm during extension.
Uses • • • •
As an assessment. Management o clinical groups 1, 2, 3a and 3b. Recent or chronic injury or episode o OA. Very pain ul elbow conditions.
Uses
Elb ow e xte ns ion with me d ia l glid e MWM – a s s e s s me nt (Fig. 5.49)
• As an assessment. • Management o clinical groups 1, 2, 3a and 3b.
• Direction: Elbow extension movement. • Symbol: Elbow E MWM med glide. 303
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• Patient starting position: Supine, lying to the right side o the couch. • Therapist starting position: Standing by the patient’s right side, acing towards the patient’s head.
Localization of forces (position of therapist’s hands and belt) • The elbow is positioned at the point o •
Localization of forces (position of therapist’s hands) • The elbow is positioned short o extension limitation or pain. • The right hand contacts the extreme distal lateral aspect o the humerus to support and stabilize the upper arm such that the shoulder is f xed in lateral rotation. • The le t hand contacts the proximal aspect o the orearm on the lateral side. • The therapist’s orearms are positioned perpendicular to the patient’s upper limb.
Application of forces by therapist (method) • The le t hand glides the proximal orearm in a medial direction, parallel to the elbow joint line. • The right hand applies a stabilizing counter orce in a lateral direction on the distal humerus. • While maintaining the medial glide, the patient actively extends the elbow.
Uses • Usually indicated when a lateral glide MWM is • • • •
not e ective. As an assessment. Management o clinical groups 1, 2, 3a and 3b. Recent or chronic injury or episode o OA. Very pain ul elbow conditions.
Elb ow e xte ns ion with me d ia l glid e MWM – b e lt (Fig. 5.50) • Direction: Elbow extension movement. • Symbol: Elbow E MWM belt med glide • Patient starting position: Supine, lying to the right side o the couch, shoulder abducted to 90° with neutral rotation. • Therapist starting position: Standing on the medial aspect o the patient’s right elbow, acing perpendicular to the arm. 304
• • •
extension limitation prior to pain onset. The right hand contacts the extreme distal medial aspect o the humerus to support and stabilize the humerus and prevent shoulder movement. The le t hand grips the lower orearm to control the movement into elbow extension. The manual therapy belt is looped around the therapist’s pelvis and extreme proximal end o the patient’s orearm. The manual therapy belt is horizontal.
Application of forces by therapist (method) • The therapist applies a medial gliding orce on the proximal orearm through the belt. • The right hand stabilizes the distal humerus. • While the glide is maintained, the patient actively extends the elbow. • The therapist moves his body to account or movement o the patient’s orearm.
Uses • Usually indicated when a lateral glide MWM is • • • •
not e ective. As an assessment. Management o clinical groups 1, 2, 3a and 3b. Recent or chronic injury or episode o OA. Very pain ul elbow conditions.
Elb ow e xion with la te ra l glid e MWM – a s s e s s me nt (Fig. 5.51) • Direction: Elbow exion movement. • Symbol: Elbow F MWM lat glide. • Patient starting position: Supine, lying to the right side o the couch. • Therapist starting position: Standing by the patient’s right side, acing towards the patient’s head.
Localization of forces (position of therapist’s hands) • The elbow is positioned at the point o
exion
limitation prior to the onset o pain. • The le t hand contacts the extreme distal lateral aspect o the upper arm to support and stabilize
Exa m in a tio n a n d tre a tm e n t te c h n iq u e s : e lb o w c o m p le x
Fig ure 5.47 • Elbow extension with lateral glide MWM.
Fig ure 5.49 • Elbow extension with medial glide MWM.
the humerus such that the shoulder is f xed in lateral rotation. • The right hand contacts the extreme proximal medial aspect o the orearm. • The therapist’s orearms are positioned perpendicular to the patient’s upper limb.
Application of forces by therapist (method) • The right hand glides the proximal orearm in a lateral direction. • The le t hand applies a stabilizing counter orce in a medial direction on the distal humerus. • While maintaining the lateral glide, the patient actively exes the elbow.
Fig ure 5.48 • Elbow extension with lateral glide MWM.
Fig ure 5.50 • Elbow extension with medial glide MWM.
Uses • As an assessment. • Management o clinical groups 1, 2, 3a and 3b. • Recent or chronic injury or episode o OA. • Very pain ul elbow conditions.
Elb ow e xion with la te ra l glid e MWM – b e lt (Fig. 5.52) • Direction: Elbow exion movement. • Symbol: Elbow F MWM belt lat glide. • Patient starting position: Supine, lying to the right side o the couch. 305
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• Therapist starting position: Standing by the patient’s right elbow, acing across the patient.
Localization of forces (position of therapist’s hand and manual therapy belt) • The elbow is positioned at the point o • • • •
exion
limitation prior to the onset o pain. The le t hand contacts the extreme distal lateral aspect o the humerus to support and stabilize the upper arm in lateral rotation. The right hand grips the lower orearm to control the movement into exion. The manual therapy belt is looped around the therapist’s pelvis and the proximal end o the patient’s right orearm. The manual therapy belt is horizontal at all times.
Application of forces by therapist (method) • The therapist applies a lateral gliding orce on the proximal orearm through the belt. • The le t hand stabilizes the distal humerus. • While the glide is maintained, the patient actively exes the elbow. • The therapist subtly moves his pelvis to the le t to account or movement o the patient’s orearm during exion.
• The right hand contacts the extreme distal lateral aspect o the humerus to support and stabilize the upper arm such that the shoulder is f xed in lateral rotation. • The le t hand contacts the extreme proximal lateral aspect o the orearm. • The therapist’s orearms are positioned perpendicular to the patient’s upper limb.
Uses • Usually indicated when a lateral glide MWM is • • • •
not e ective. As an assessment. Management o clinical groups 1, 2, 3a and 3b. Recent or chronic injury or episode o OA. Very pain ul elbow conditions.
Elb ow e xion with me d ia l glid e MWM – b e lt (Fig. 5.54) • Direction: Elbow exion movement. • Symbol: Elbow F MWM belt med glide • Patient starting position: Supine, lying to the right side o the couch, shoulder abducted to 90° with neutral rotation. • Therapist starting position: Standing on the medial aspect o the patient’s right elbow, acing perpendicular to the arm.
Uses • • • •
As an assessment. Management o clinical groups 1, 2, 3a and 3b. Recent or chronic injury or episode o OA. Very pain ul elbow conditions.
Localization of forces (position of therapist’s hands and belt) • The elbow is positioned at the point o •
Elb ow e xion with me d ia l glid e MWM – a s s e s s me nt (Fig. 5.53) • Direction: Elbow exion movement. • Symbol: Elbow F MWM med glide. • Patient starting position: Supine, lying to the right side o the couch. • Therapist starting position: Standing by the patient’s right side, acing towards the patient’s head.
• • •
exion
limitation prior to pain onset. The le t hand contacts the extreme distal medial aspect o the humerus to support and stabilize the upper arm and prevent shoulder movement. The right hand grips the lower orearm to control the orearm movement during elbow exion. The manual therapy belt is looped around the therapist’s pelvis and extreme proximal end o the patient’s orearm. The manual therapy belt is horizontal at all times.
Localization of forces (position of therapist’s hands)
Application of forces by therapist (method)
• The elbow is positioned prior to the point o
• The therapist applies a medial gliding orce on
exion limitation or prior to the onset o pain. 306
the proximal orearm through the belt.
Exa m in a tio n a n d tre a tm e n t te c h n iq u e s : e lb o w c o m p le x
Fig ure 5.51 • elbow exion with lateral glide mwm.
Fig ure 5.52 • elbow exion with lateral glide mwm.
Fig ure 5.53 • Elbow exion with medial glide MWM.
• The le t hand stabilizes the distal humerus. • While the glide is maintained, the patient actively exes the elbow. • The therapist subtly moves his pelvis to the right, to account or movement o the patient’s orearm during exion.
Uses • Usually indicated when a lateral glide MWM is not e ective.
Fig ure 5.54 • Elbow exion with medial glide MWM.
• • • •
As an assessment. Management o clinical groups 1, 2, 3a and 3b. Recent or chronic injury or episode o OA. Very pain ul elbow conditions.
Elb ow e xte ns ion with ulna r la te ra l tilt MWM (Fig. 5.55) • Direction: Elbow extension movement. • Symbol: Elbow E MWM ulnar lat tilt. 307
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• Patient starting position: Supine, lying to the
• Patient starting position: Supine, lying to
right side o the couch, arm by the side. • Therapist starting position: Standing by the patient’s right side, acing towards the patient’s head.
the right side o the couch, arm by the side. Shoulder in 90° exion and lateral rotation. • Therapist starting position: Standing lateral to the patient’s right shoulder, acing across the patient.
Localization of forces (position of therapist’s hands) • The elbow is positioned short o extension limitation or pain. • The thenar eminence o the right hand contacts the medial border o the ulnar. • The le t hand contacts the distal aspect o the humerus on the lateral side. • The therapist’s hands ‘cup’ posteriorly the patient’s orearm and humerus.
Application of forces by therapist (method) • The right hand tilts the ulnar in a lateral direction, rotating the ulnar along its long axis, through a supination movement o the therapist’s right orearm. • The le t hand applies a stabilizing counter orce in a lateral direction on the distal humerus. • While maintaining the lateral tilt, the patient actively extends the elbow.
Uses • As an assessment. • Limitation o elbow extension, particularly associated with throwing action.
Elb ow e xte ns ion with ulna r me d ia l tilt MWM (Fig. 5.56) • Direction: Elbow extension movement. • Symbol: elbow E MWM ulnar med tilt. • This technique is similar to the previous technique, with the exception that the therapist’s le t hand tilts the ulnar medially, via contact on the lateral border o the ulnar. The therapist’s right hand now stabilizes the lateral aspect o the humerus.
Elb ow e xion with longitud ina l c a ud a d glid e MWM (Fig. 5.57) • Direction: Elbow exion movement. • Symbol: Elbow F MWM ulnar caud. 308
Localization of forces (position of therapist’s hands) • The elbow is positioned short o
exion
limitation or pain. • The therapist’s right ‘cupped’ palm (between thenar and hypothenar eminences) contacts the proximal aspect o the patient’s olecranon, taking up the so t tissue slack to ensure a f rm contact. • The le t hand contacts the anterior distal anterior aspect o the humerus. • The therapist’s orearms are positioned such that they are parallel to each other, with the therapist’s right orearm aligned with the patient’s right orearm.
Application of forces by therapist (method) • The right hand glides the olecranon in longitudinal caudad direction. • The le t hand applies a stabilizing counter orce on the distal anterior humerus, to stabilize the upper arm. • While maintaining the glide, the patient actively exes the elbow.
Uses • As an assessment. • Limitation o elbow exion.
Elb ow p rona tion or s up ina tion with ra d ius MWM (Fig. 5.58) • Symbol: Elbow Sup. MWM
or
radius; elbow Sup. MWM radius; elbow Pro. MWM radius; elbow Pro. MWM radius. • Patient starting position: Supine, lying to the right side o the couch, elbow exed to 90°. • Therapist starting position: Standing by the patient’s right side, acing across the patient.
Exa m in a tio n a n d tre a tm e n t te c h n iq u e s : e lb o w c o m p le x
Localization of forces (position of therapist’s hands) • The elbow is positioned short o pronation or supination limitation or pain. • The thumbs o both hands (one rein orcing on top o the other) contact the anterior or posterior aspect o the proximal aspect o the radius.
Application of forces by therapist (method) • With both thumbs the therapist applies either a PA or AP glide on the radius.
• The f ngers and palms o the therapist’s hands provide general stability to the proximal orearm and elbow.
Uses • Limitation o orearm pronation or supination.
Techniques or lateral epicondylalgia The ollowing techniques are described or a patient with lateral epicondylalgia, where the pain provoking
Fig ure 5.55 • Elbow extension with ulnar lateral tilt MWM.
Fig ure 5.56 • Elbow extension with ulnar medial tilt MWM.
Fig ure 5.57 • Elbow exion with longitudinal caudad glide MWM.
Fig ure 5.58 • Elbow pronation or supination with radius MWM.
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activity is making the f st (gripping). The same tech nique could be applied where isometric f nger and/ or wrist extension is provocative.
Grip p ing with la te ra l glid e MWM (Fig. 5.59)
Uses • As an assessment. • To eliminate pain associated with gripping to make a f st and wrist or f nger isometric extension.
lateral direction. • The le t hand applies a stabilizing counter orce in a medial direction on the distal humerus. • While maintaining the lateral glide, the patient grips to make a f st.
Variations on this technique include the use o a manual therapy belt to apply the lateral glide orce, rather than the therapist’s hands (Fig. 5.60). In some patients it is necessary to adjust the angle o the gliding orce, as the glide that achieves the pain ree activity is not always in a purely lateral direc tion. At least 66% o maximum glide orce is required to achieve optimum improvement (McLean et al. 2002). The patient can be instructed to carry out a lateral glide at the elbow, while making a f st, as a home exercise. This will greatly enhance recovery. Taping is a use ul adjunct treatment when the a orementioned technique has been ound to be e ective. Two strips o 38 mm non stretch sports tape are applied rom the medial aspect o the orearm, spiralling proximally across the anterior aspect o the elbow, to f nish on the posterior aspect o the humerus on the lateral side (Fig. 5.61). Both strips overlay each other. To achieve some degree o tension the tape should be applied with the elbow slightly exed and maximally supinated. I tape is applied under tension, then when the elbow is in an extended/ pronated position, urther tension will be generated, which should produce a degree o lateral orce. The patient’s symptoms should be assessed be ore and a ter the tape is applied. A signif cant improvement in the pain ree grip orce indicates
Fig ure 5.59 • Gripping with lateral glide MWM.
Fig ure 5.60 • Gripping with lateral glide MWM.
• Symbol: Lat glide grip MWM. • Patient starting position: Supine, lying to the right side o the couch, arm by the side, elbow extension and orearm pronation. • Therapist starting position: Standing by the patient’s right side, lateral to the elbow, acing towards the patient’s head.
Localization of forces (position of therapist’s hands) • The elbow is positioned in ull pronation and extension. • The le t hand contacts the extreme distal lateral aspect o the upper arm to support and stabilize the humerus such that the shoulder is f xed in lateral rotation. • The right hand contacts the extreme proximal medial aspect o the orearm. • The therapist’s orearms are positioned perpendicular to the patient’s upper limb.
Application of forces by therapist (method) • The right hand glides the proximal orearm in a
3 10
Exa m in a tio n a n d tre a tm e n t te c h n iq u e s : e lb o w c o m p le x
a positive outcome. In that case the tape is usually worn or 48 hours be ore removal, skin inspection, and reapplication i necessary. Prior to the f rst application, it is important to assess or any con traindications (skin allergy, open wounds, in ection, etc.), and to warn the patient about occurrence o potential side e ects, which requires the imme diate care ul removal o tape to prevent skin breakdown.
Grip p ing with
ra d ius MWM (Fig. 5.62)
• Symbol: radius grip MWM. • Patient starting position: Supine, lying to the right side o the couch, arm by the side, elbow extension and orearm pronation. • Therapist starting position: Standing by the patient’s right side, lateral to the elbow, acing across the patient.
Localization of forces (position of therapist’s hands) • The elbow is positioned in ull pronation and
Application of forces by therapist (method) • With both thumbs the therapist applies either a posteroanterior glide on the radius. • The f ngers and palms o the therapist’s hands provide general stability to the proximal orearm and elbow.
Uses • As an assessment. • To eliminate pain associated with gripping to make a f st and wrist or f nger isometric extension. The patient can be instructed to carry out a poster oanterior glide o the radius, while making a f st, as a home exercise. This will greatly enhance recovery. Taping can mimic a posteroanterior glide o the radius (Fig. 5.63). Apply two short strips o 38 mm non stretch sports tape rom the posterior aspect o the head o the radius, wrapping around the orearm to end on the medial aspect o the orearm.
extension. • The thumbs o both hands (one rein orcing on top o the other) contact the posterior aspect o the proximal aspect o the radius.
Fig ure 5.62 • Gripping with
Fig ure 5.61 • Tennis elbow tape lateral glide.
radius MWM.
Fig ure 5.63 • Tape for PA radius. 3 11
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Manag e me nt o f e lbo w dis o rde rs
Lay the tape under tension, pulling the tape in an anterior direction, while at the same time apply ing a posteroanterior gliding orce on the head o the radius.
Neurodynamic techniques Treatment or elbow disorders, where peripheral nerve sensitization can be identif ed as the pain source, should consist o gentle manual therapy in which the structures surrounding the involved neural tissue are gently mobilized. The cervical lateral glide is the technique o choice or patients with peripheral nerve sensitization involving the upper limb (H all & Elvey 2011).
Ce rvic a l la te ra l glid e te c hniq ue (Fig. 5.64) • Direction: Cervical lateral glide. • Symbol: Cx lat glide. • Patient starting position: Supine, lying in the centre o the couch, with the top o the head level with the end o the couch. Both hands resting on the abdomen. • Therapist starting position: Standing at the patient’s head, the therapist rests their abdomen against the top o the patient’s head.
Localization of forces (position of therapist’s hands) • The cervical spine is positioned in neutral, with the individual sensitized peripheral nerve trunk positioned out o provocation (hands resting on the abdomen, with the elbows exed to 90°). • The le t hand contacts the posterior aspect o the cervical spine, with the f ngers and thumb wrapping around each side o the neck. The index f nger should be immediately proximal to the most sensitized cervical segment. • The right hand contacts the superior sur ace o the patient’s right acromion to stabilize the scapula and prevent elevation.
Application of forces by therapist (method) • The le t hand translates the head and cervical spine in a contralateral direction, returning to neutral position, oscillating between each end point. 3 12
Fig ure 5.64 • Cervical lateral glide.
• The patient’s arm is positioned, during ollow on treatment sessions, in progressively greater degrees o neural tissue provocation as mechanosensitivity diminishes.
Uses • When pain predominates rom peripheral nerve sensitization involving the median, radial, or ulnar nerve trunk around the elbow.
Sc a p hoid IV a nd V (Fig. 5.65) • Direction: Wrist extension movement. • Symbol: PA scaphoid IV and V.
Elb o w d is o rd e rs a n d th e ir c lin ic a l p ro le s
amplitude, posteroanterior pressure on the scaphoid.
Variations in the application of forces G entle traction can be employed during the applica tion o orce against the scaphoid to separate the carpal articular sur aces.
Uses • Elbow lateral epicondylalgia. • When wrist extension is most pain ul and
Fig ure 5.65 • Scaphoid high velocity thrust.
• Patient starting position: Supine, lying with the shoulder in abduction, elbow in extension, orearm pronation. • Therapist starting position: Standing by the patient’s right side just beyond the elbow, acing the patient’s head.
Localization of forces (position of therapist’s hands)
restricted. • For localized pain and restriction o movement o the radioscaphoid articulations.
Elbo w dis o rde rs and the ir c linic al pro le s Introduction The most common types o elbow neuromuscu loskeletal disorder all into the ollowing broad categories:
• Trauma – particularly ractures o the head o
• The therapist holds the patient’s right hand. • The thumbs o each hand overlay each other,
•
contacting the dorsal aspect o the scaphoid. • The index f ngers o each hand overlay each other, contacting the ventral aspect o the scaphoid. • The remaining f ngers support the hand and control the movement o the wrist.
•
Application of forces by therapist (method)
•
•
• The therapist exes the patient’s elbow and wrist simultaneously, ollowed by extension o the wrist and elbow. When this technique is used in treatment as a grade IV the slack o the so t tissues must be taken up f rst. • As the therapist extends the wrist, the thumbs apply f rm ventrally directed pressure to the scaphoid. • Small oscillatory movements can be per ormed through range o wrist extension. • A high velocity thrust (grade V) can be applied by a quick ick o the patient’s wrist into extension combined with rapid, small
• •
•
radius and olecranon, subluxation o the head o radius, and apophyseal separation in children. O veruse strain – especially medial and lateral epicondylalgia (Table 5.2) and valgus extension overload rom throwing or racket use (Ellenbecker et al. 2010a). Peripheral nerve sensitization – especially the ulnar and radial nerves. Peripheral nerve compression (CN ) – especially the ulnar nerve in the cubital tunnel. O steoarthritis (mechanical, degenerative, traumatic or systemic) which may include impairment due to loose bodies. Rheumatoid arthritis. O steochondrosis – Panner’s disease (medial epicondyle apophysitis) is the most common cause o elbow pain in children under 10 years (Atanda et al. 2011). Less common conditions include osteochondritis dissecans, olecranon bursitis and myositis ossif cans.
Maitland (2001) has categorized elbow disorders by their common clinical characteristics. The purpose o this is to help establish the role which mobilization/ 3 13
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Table 5.2 Clinical pro le: lateral epicondylalgia
Examination
Clinical evidence/‘brick wall’ thinking
Kind of disorder
Predominantly multidimensional involving three interrelated components. These are: (1) extensor tendon pathology, (2) changes in the pain system, and (3) motor system impairments (Coombes et al. 2009). Most commonly pain on the lateral side of the elbow occurs with gripping, forearm pronation and wrist/ nger extension activities
Body chart features
Lateral elbow pain Joint: deep aching pain within the joint; feeling of stiffness Radial nerve: Proximal/distal spread of pain; lines of pain; accompanying sensitivity to touch (allodynia, hyperalgesia). Pain, dysaesthesia, occasional paraesthesia in the distribution of the sensory branch of the radial nerve Muscle/tendon: super cial pain local to the common extensor origin; sore, bruised feeling; feeling of weakness in the arm and tiredness of the forearm muscles Other sources: heaviness of the whole arm, diffuse pain; dysaesthesia; the characteristic dermatomal distribution of nerve root pain in cervical radiculopathy
Activity limitations/ 24-hour
Reduced grip strength often accompanied by pain. Pain and weakness behaviour of symptoms reproduced during activities involving gripping or lifting items with elbow extended Joint disorders accompanied by stiffness and limitation by pain during activities which involve elbow extension, pronation or supination depending on the predominant joint involved, such as reaching and lifting a heavy saucepan, or opening a stiff door. Morning stiffness is common in arthritic joints or in ammatory arthropathies Disorders with radial nerve involvement will be affected by activities which enhance the mechanosensitivity of the affected nerve, including activities which lengthen sensitized neural tissue such as keyboard use, carrying shopping bags, muscle stretching Muscle/tendon disorders will show up as pain or pain inhibition during gripping activities. However, gripping is also known to cause compression of the radial nerve in the supinator tunnel, and strain painful joints. Isolated referred pain from the cervical spine is generally unaffected by activities which would usually stress the tissues around the elbow
Present/past history
Although commonly called tennis elbow, this condition affects more industrial workers than sportsmen (Van Hofwegen et al. 2010). Occupations/activities involving non-neutral postures of hands and arms, use of heavy handheld tools, and high physical strain are particularly at risk (Haahr & Andersen 2003). The condition is prone to recurrent bouts and is characterized by a protracted history
Special questions
MRI should be considered to exclude other conditions such as osteochondral lesions, non-displaced epiphyseal fractures and other underlying bone problems (Van Hofwegen et al. 2010). If these are not suspected no further screening is recommended
Source/ mechanisms of symptom production
Primarily degenerative tendinopathy, chemical/mechanical nociception, or peripheral neurogenic pain from nerve sensitization or, very rarely, true radial nerve entrapment. Consider also cervical nerve root pain
Cause of the source
Consideration should be given to the cervical spine (Berglund et al. 2008, Cleland et al. 2004), neural tissue involvement (Berglund et al. 2008, Buzzi & Moskowitz 2005, Waugh et al. 2004, Yaxley & Jull 1993) and poor dynamic control (Bisset et al. 2006b, Ellenbecker et al. 2010b)
Contributing factors
Occupation; pre-existing degenerative changes in tendon connective tissue; central sensitization of nociceptive tissue
Observations
Swelling or prominence of the lateral epicondyle; overactivity of ECRB (elbow exed); muscle atrophy is more likely to be related to disuse rather than the rare event of true posterior interosseous nerve compression (Rosenbaum 1999)
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Elb o w d is o rd e rs a n d th e ir c lin ic a l p ro le s
Table 5.2 Clinical pro le: lateral epicondylalgia—cont’d
Examination
Clinical evidence/‘brick wall’ thinking
Functional demonstration
Grip strength test with elbow in extension and pronation; minor restriction of joint movements ( exion, extension, pronation, supination); active neurodynamic screening tests for the radial nerve involvement may be helpful (Hall & Elvey 2011)
If necessary tests
Lower cervical quadrant for reproduction of symptoms consistent with cervical nerve root compression (in the absence of arm pain reproduction, consider combining with axial compression); ick at the end of elbow exion, extension, pronation, supination as overpressure if movements previously symptom free
Other structures in plan
Screening tests for shoulder, wrist and hand, thoracic spine
Isometric/muscle length tests
Pain and weakness with grip strength tests, wrist extension, and nger extension; alignment faults in gripping with increased wrist exion (Bisset et al. 2006b); pain-free grip force is a more valid measure of outcome (Stratford et al. 1995)
Neurological examination
Sensory loss and motor loss in peripheral nerve distribution if nerve entrapment at the elbow; re ex, dermatome or myotome changes if nerve root lesion
Neurodynamic testing
Pain reproduction, altered range, and increased resistance to movement on radial nerve neurodynamic testing
Passive movement
Spongy thickening and swelling in the olecranon fossa may be palpable and cause lateral elbow pain
Palpation ndings
Soft tissue changes evident over the joint line of the radiohumeral joint if there is joint involvement. Tenderness and swelling of the common extensor origin may be palpable, and gentle pressure on the radial nerve may reveal abnormal sensitivity to touch (Berglund et al. 2008)
Accessory/ physiological
Minor signs. Reproduction of symptoms and joint signs with combined movements,extension/adduction, extension/abduction, exion/adduction, exion/abduction, extremes of pronation and supination, and anteroposterior/posteroanterior pressure on the head of the radius
Mobilization/ manipulation
Usually t into the category of chronic minor symptoms in which case the preferred techniques will be MWM. Lateral glide of the elbow or posteroanterior glide of the head of the radius with grip should be trialled. In addition elbow extension/adduction grade IV to IV[+] and accessory movements at the limit of range, usually anteroposterior/posteroanterior on the head of the radius in pronation may also be helpful. The desired effects of such techniques are pain relief and restoration of ideal function. Associated techniques to consider are cervical mobilization (lateral glide), and neurodynamic ‘sliders’ in the presence of signi cant peripheral sensitization of the radial nerve. Recently elbow manipulation and Cyriax transverse friction have not been found to be effective (Stasinopoulos & Johnson 2004, Stasinopoulos & Stasinopoulos 2006). Consider manipulation of the wrist
Other management strategies
Short-term bene t of cortisone injection, reversed at mid- and long-term (Coombes et al. 2010); therapeutic exercise programme effective but usually given in combination with manual therapy (Coombes et al. 2009, Bisset et al. 2005), sports taping (Vicenzino et al. 2003)
Prognosis/ natural history
Prognostic factors predicting recovery have been identi ed. These include work-related disease, length of history of the disease, ergonomic risk exposure, job stress, level of job support, and pain-coping style (Feuerstein et al. 2000). Another report suggested that the psychological status of the patient is important (Alizadehkhaiyat et al. 2007a). The presence of neural symptoms in the arm, and cervical joint signs, has been associated with poor short-term outcome (Waugh et al. 2004)
Evidence base
A multimodal approach has been proposed to manage lateral epicondylalgia due to the complexity of this condition’s pathophysiology and the heterogeneity of clinical presentation (Coombes et al. 2009). Furthermore, evidence suggests a multimodal approach is more effective than local treatment alone (Cleland et al. 2004) 3 15
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manipulation can play in such disorders. The main characteristics to consider are:
• Lateral epicondylalgia • Joint sti ness • Chronic minor joint pain.
Lateral epicondylalgia Pain over the lateral epicondyle associated with wrist and hand activity is commonly known as tennis elbow, but the correct term is lateral epicondylalgia. This disorder is common in both men and women between the age o 35 and 54 and particularly a ects the dominant arm in racquet sports and manual occupations (Shiri et al. 2006). Despite the rela tively simple clinical picture, the underlying patho physiological mechanisms are complex (Vicenzino 2003) and can be conceptualized as encompassing three interrelated components (Coombes et al. 2009). These are: (1) extensor tendon pathology, (2) changes in the pain system, and (3) motor system impairments. Pathology o the tendon may be the result o overuse, underuse, or tensile, compressive or shear orces, which leave the tendon in a debili tated state (Coombes et al. 2009). Despite the complexity, the potential or locally applied manual therapy to help relieve pain and restore unction has been demonstrated in a number o trials (Amro et al. 2010, Bisset et al. 2006a, Drechsler et al. 1997, Kochar & Dogra 2002). Care ul examination o the elbow will requently reveal a variety o joint signs potentially contributing to the generation o the patient’s symptoms. Box 5.5 highlights some o the variations in potential diagnosis in lateral epicondylalgia and the primacy o selecting treatment techniques based on the clinical in orma tion as it emerges. When minor joint signs are present they can be used as the passive movement treatment tech niques. In particular MWM consisting o a pos teroanterior glide on the head o radius (Fig. 5.62), or lateral glide o the elbow (Fig. 5.60), combined with gripping has been shown to be an e ective treatment technique (Bisset et al. 2006a). Taping (Figs 5.61 and 5.63) may provide long term pain relie and encourage return to more normal activ ity. Combined with this should be exercise to stimulate tendon remodelling, produce muscular adaptive responses and improved dynamic control o the whole upper limb kinetic chain. In addition, treatment should be directed to mobilize the spine 3 16
Box 5 5 Lateral epicondylalgia: varied presentations Clinic a l p re s e nta tion 1 Localized lateral elbow pain with li ting s aucepan Came on a ter li ting heavy pot • Cervical s pine, thoracic s pine • Shoulder , elbow E/Ab s light pain • Is ometric wris t extens ion pain ++ • MWM – on radial head relieves pain on wris t extens ion Probable localized elbow problem 2 Whole arm aches , es pecially around the lateral elbow and into the orearm Occas ional thumb pins and needles Some neck s ti nes s Arm aches with s itting • Elbow , is ometrics • Cervical rotation to the s ide o the arm – reduced ROM by a ew degrees • Spurling’s tes t pos itive or arm pain • Neurodynamic tes ts provoke arm paraes thes ia only • C6/7, locally s ore and s ti Probable cervical nerve root involvement – CN 3 Lateral epicondyle pain radiates proximally with reaching movement Aches at the end o the day with us e • Elbow – E/Ad pain ++ • Elbow – extens ion/pronation pain, wors e in s houlder abduction/cervical lateral f exion • Radial nerve neurodynamic tes t pos itive or arm pain and reduced ROM • Radial nerve hyperalges ic proximal and dis tal to elbow • C4–5 s ti , s ore locally • Neurological examination normal Probable PNS
and desensitize the radial nerve, i ound to be involved in the disorder. A multi aceted manual therapy treatment approach, such as that presented here, has been shown to be more e ective than localized treatment to the elbow alone (Cleland et al. 2004).
J oint s ti nes s It is clear that judicious, thought ul and controlled stretching o the elbow (grades III and IV) is unlikely to cause trauma and myositis ossif cans.
Elb o w d is o rd e rs a n d th e ir c lin ic a l p ro le s
I a patient has a sti and pain ul elbow (clinical groups 3a and 3b), mobilization techniques should be directed towards in uencing the movement related pain f rst until a clear picture o the irri tability and behaviour o the pain emerges. O nce this is known, treatment can be directed towards stretching the elbow in any direction, provided progression o the strength o the technique used does not un avourably alter the pattern o pain. In such cases the stretching technique will be completely sa e. The stretching techniques or a sti elbow should consist o : 1. physiological movement grade IV or IV+ provided pain is minimal; 2. accessory movements grade IV or IV− with the joint supported at the limit o the physiological range; 3. interspersing between physiological IV and accessory IV at the limit o range; 4. grade III+ through as large a range as possible to minimize the e ects o treatment soreness.
Chronic minor joint pain When a patient’s elbow symptoms are compara tively minor, or are longstanding but still having an e ect on the patient’s daily li e, there are certain passive examination tests, which must be assessed (Box 5.6). In examination and then treatment, accessory movements at the limit o the various ranges o movement may help to determine which o the three elbow joints is primarily at ault. Extension/ abduction and extension/ adduction may well pro vide the most comparable joint signs in such cases; accessory movements at limit and E/ Ab and E/ Ad are there ore most commonly used in treatment. The elbow joint can easily be over treated, whether pain or sti ness is the prime consideration. I a technique such as extension is being used it is vital that the patient’s arm is completely relaxed during the treatment and the technique should be completely ree o even the most minor eeling o discom ort (III−) (Fig. 5.35A). I the patient’s symptoms are comparatively mild and extension is being used, a gentle grade IV can be considered as a relevant treatment technique, applied more slowly than usual so as to provoke only a minimal amount o pain. This will ensure that the patient’s pain is not exacerbated.
Box 5 6 Important passive movement tests for elbow symptoms •
Supine: f exion and extens ion, plus abduction and adduction • Supination and pronation plus and plus compres s ion • Longitudinal caudad (humeral line) in 90° elbow f exion • Olecranon movements • Functional tes t, grip (s mall and large) in F, E, Sup, Pron • Is ometric and mus cle length tes ts Tes t movements begin as IV− with obs ervation or pain res pons e I pain ree, adequate overpres s ure is applied until pain is provoked or the movement is judged ‘clear’ When a pos itive pain res pons e is provoked, that tes t movement may need to be di erentiated to determine the s peci c joint at ault, and/or other movements may need to be tes ted s o as to either exclude or incriminate other joints as contributing to the s ymptoms I all tes t movements appear ‘clear’ at rs t examination, they s hould be repeated more s trongly
Box 5 7 Proving that the elbow joints are, in fact, unaffected • • •
Supine: extens ion/abduction Extens ion/adduction and ‘s couring’ Supination and pronation with IV+ OP Olecranon tes ts
Proving the elbow una ected The elbow joints can be screened thoroughly to prove that they are una ected in disorders o the upper limb where the elbow could be a source, or cause o the source, o the patient’s symptoms (Box 5.7). These three passive movements should be per ormed as grade IV− movements.
Compos ite elbow Box 5.1 lists the test movements that need to be per ormed i it is not clear which o the three elbow 3 17
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Manag e me nt o f e lbo w dis o rde rs
joints is responsible or the patient’s symptoms. Further di erentiation o the test movements should reveal which joint is the source. For example, supination at its limit may be pain ul. This could be due to torsion o the humeroulnar joint or spin o
the head o the radius against the ulna and sliding o the head o the radius under the capitulum. Supination can then be per ormed in ways that will establish which joint is causing the patient’s pain.
Cas e s tudy 5 1 A clinical example of recording – the elbow region Mr K is a 25-year-old motor mechanic who enjoys s ur ng two to three times per week
Ac tivity limita tions /24-hour b e ha viour of s ymp toms
Kind of d is ord e r
** pus h-ups at gym – immediate pain – eas es in a ew minutes us ing a s crewdriver with elbow extended – ons et in 10 s econds – aches or one minute
Elbow pain with elbow extens ion and s upination
Bod y c ha rt Areas o s ymptoms are as outlined in Figure 5 66
1 Int deep ache 2 Int deep ache
Relations: 1 and 2 separate
Fig ure 5.66 • Body chart of Mr K.
3 18
Elb o w d is o rd e rs a n d th e ir c lin ic a l p ro le s
Cas e s tudy 5 1—cont’d Sle e p Works as a s mall motor mechanic repairing motors – – EOD
P a s t/p re s e nt his tory •
• •
• • • •
commenced a ter a all onto a s andbar while s ur ng 12 weeks ago Fell onto outs tretched arm – no hyperextens ion Experienced immediate pain, although was able to keep s ur ng or another 30 minutes No previous his tory o Very s ore next morning Since then, had f uctuating s ymptoms though currently about the s ame commenced a week later and has remained about the s ame s ince Cons ulted medical practitioner our weeks ago, who pres cribed analges ics as required and X-rays He has had no treatment or the problem at this s tage No relevant previous his tory o upper limb injury or problems
•
•
• • • •
Sp e c ia l q ue s tions General health – NAD X-rays our weeks ago – NAD Medication – analges ia as required
Hyp othe s is • •
•
Elbow s prain due to all on outs tretched arm The his tory s ugges ts probable res idual dys unction o the humeroulnar joint and the radiohumeral joint and the s uperior radioulnar joint The s everity and irritability are low, s ugges ting that the examination and treatment can be to the limit o the movement directions
•
Cervical S pine Quadrant Wrist Flexion , extens ion , ulnar deviation , radial deviation Active movements : Elbow extens ion: P1 5° f exion P2R2 with OP Elbow f exion: Forearm s upination: P1 75°P2 OP Forearm pronation: Palpation (elbow): Tender proximal to olecranon Tender over radiohumeral joint line Is ometric tes ts : (Mus cle length not tes ted) Neurodynamic active s creening tes ts : radial , median, , ulna Neurological examination: Pas s ive movements (joints ): Extens ion R1 10° f exion P1 5° f exion P2R2 OP 0° f exion ( ) Supination: R1 70° P1 80° R2P2 OP 90° head o radius ++ As s es s ment us ing MWM or extens ion: Medial and lateral glide – no change to elbow extens ion Apply lateral tilt on olecranon – pain ree Sus tain lateral tilt on olecranon with active elbow extens ion – pain- ree movement into extens ion and able to extend to end-range active extens ion 0° MWM repeated × 10 Pos t-technique active extens ion ull end range pain only with OP Supination unchanged
P hys ic a l e xa mina tion
P la n for tre a tme nt 1
Obs ervation: holds the elbow in s lightly increas ed f exion compared to the le t s ide Pres ent pain: nil
Treat elbow extens ion initially us ing MWM Evaluate inf uence on s upination and progres s s ubs equent treatment according to res pons e to MWM
Functional demons tration and di erentiation:
Rx1 Treatm ent
•
Quick tes t: Elbow m ovem ents Extens ion elbow pain and res triction Flexion Pronation Supination: EOR pain and res triction S houlder m ovem ents Elevation through f exion Abduction Hand behind back
Elbow extens ion MWM with lateral tilt – two s ets o 10 repetitions
A ter treatm ent Active extens ion P1R2 with OP only Supination unchanged
Rx2a Assessm ent C/O− elbow pain improved 40% , unchanged Elbow extens ion pain on OP Supination unchanged
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Cas e s tudy 5 1—cont’d Treatm ent 2a
Post treatm ent
MWM elbow extens ion with lateral tilt – three s ets o 10 repetitions
Active extens ion Supination P1 OP head o radius
Post-treatm ent Active extens ion Supination unchanged
head o radius
++
Treatm ent 2b 3×
C/O elbow pain improved 100% , Elbow extens ion Supination P1 OP head o radius
head o radius grade III−
Post-treatm ent 2b Active extens ion Supination P1 85° P2 OP head o radius
improved 80%
Treatm ent 5×
Rx3 Assessm ent C/O− elbow pain improved 80% , Elbow extens ion pain on OP Supination P1 85° P2 OP head o radius +
Rx4 Assessm ent
head o radius grade III+
Post-treatm ent improved 30%
Elbow extens ion Supination head o radius
Rx5 Assessm ent
Treatm ent MWM elbow extens ion with lateral tilt – three s ets o 10 repetitions with OP 3 × head o radius grade III Home exercis e MWM us ing elbow extens ion with ulnar lateral tilt – three s ets o 10 per day
C/− elbow pain improved 100% , improved 100% Elbow extens ion Supination Advice given to maintain improvement by non-s peci c ROM exercis es or extens ion and s upination
Re erences Alizadehkhaiyat O, Fisher AC, Kemp G J, et al: Pain, unctional disability, and psychologic status in tennis elbow, Clin J Pain 23:482–489, 2007a. Alizadehkhaiyat O, Fisher AC, Kemp G J, et al: Strength and atigability o selected muscles in upper limb: assessing muscle imbalance relevant to tennis elbow, J Electromyogr Kinesiol 17:428–436, 2007b. Amro A, Diener I, O mar Bdair W, et al: The e ects o Mulligan Mobilisation with movement and taping techniques on pain, grip strength and unction in patients with lateral epicondylitis, H ong Kong Physiother J 28:19–23, 2010. An KN, Chao EY, Morrey BF, et al: Intersegmental elbow joint load during pushup, Biomed Sci Instrum 28:69–74, 1992. 320
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C H AP TE R C O N TE N TS Introd uc tion
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Sub je c tive e xa mina tion (C/O)
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P la nning the p hys ic a l e xa mina tion (P /E)
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Key words In erior radioulnar joint, radiocarpal, midcarpal, intercarpal, carpometacarpal, intermetacarpal, metacarpophalangeal, interphalangeal
Intro duc tio n The bio-psychosocial role of the hand is greater than that of any other part of the body. H ofer (2009) has long recognized the role of the tactile kinaesthetic system (touch or feeling) in the development of mankind. The hand and the brain act as a functional unit. The hand occupies a central place and is highly represented within the sensory homunculus. The hand within the sensory homunculus plays an important role in maintaining internal homeostasis and balance relative to the socioemotional environment and functioning. The development of mankind has been characterized by an interaction between man, as an individual, and his environment and an unlimited range of activities. The hand tells us about centuries of evolving sensations and functional applications of many different kinds. Several professions are totally dependent on perfect function of the hand, including the 324
requirement for great adaptability which, along with a great capacity for differentiation of a vast range of functions, is a development acquired over many years. All those qualities are found not only among artists (musicians, jewellers, etc.), but also in a range of professions including carpenters, watchmakers and surgeons. The hand is more than a tool – it is a means of expression and non-verbal communication. It is a means of being able to carry out work, which, in effect, represents the essence of life and which de nes a person’s existence. Manual therapists, too, are clearly a professional group whereby if they experience a small loss of function of the hand, there will be major consequences in terms of participation (job and hobbies) and quality of life (feeling of ful lment). The effect of the smallest derangement or disease on functioning and disability is crucial. The International Classi cation of Functioning, Disability and H ealth (ICF) (WH O 2001) provides an ideal framework for identifying the impact of hand disorders on functioning, participation and social and environmental factors in an individual’s life. The consequences for the manual therapist of working within such a framework of clinical practice is that it forces the clinician to consider not only the input pain mechanism of nociception and peripheral neurogenic pain, but also the associated and consequential processing of the individual’s experience and how this impacts on their ability to lead a ful lling life. Where processing of the pain experience is concerned, chronicity will be a major factor resulting in sensitization of the central nervous system (CNS).
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This, in turn, adds to the factors perpetuating and contributing to the incidence and prevalence of hand disorders in populations. Understanding pain mechanisms and how they affect the patient experiences and responses will, therefore, play an important role in the management of hand disorders. Moseley et al. (2008) suggest that chronic pain may lead to reduced tactile acuity and that a clear relationship exists between pain intensity, tactile acuity and cortical reorganization. Their research shows that when pain resolves, tactile function improves and cortical organization normalizes. This demonstrates yet again the close relationship between hand and brain. If, in relation to pain mechanisms, the primary problem is one of nociception causing a localized pain experience, the aim of manual therapists is to reduce, relieve and put an end to it. If chronic central sensitization is driving symptoms in the hand, the aim of management is to try to allow the patient to cope with it, to accept it and to perform adapted functional exercises including automobilization. The hand needs to be examined very speci cally and in detail with an attention to differentiation testing wherever possible. H and function is complex and ne-tuned with a multitude of adaptive capabilities which, for example, have to be able to enhance subtle and profound feelings for playing a melody on a piano, allow a capacity to build and move the same piano and even enable the chopping down of the tree which will eventually become the said piano. The examiner will have to show a lot of creativity, exibility of mind and imagination to reproduce the multitude of possible functions and they must have a deep commitment to review and analysing the great subtlety, neness and vigour of hand function. The complex and detailed role of the wrist and hand in both prehensile and non-prehensile functions and the neness of this organ’s sensory and motor representation warrant attention to detail in the clinical study of the relationships between the joints, muscles and nerves of the wrist and hand. Mobilization/ manipulation has a place in the management of neuromusculoskeletal disorders of the wrist and hand alongside many other rehabilitation strategies. This chapter offers the clinician an opportunity to examine and physically treat the articular impairments of wrist and hand disorders and, at the same time, to recognize the in uence
of the neural, musculotendinous, fascial and vascular systems upon such disorders. The aim of the manipulative physiotherapist, therefore, is to contribute to the physical, psychosocial and socioeconomic rehabilitation of the patient with wrist and hand impairments. To achieve the desired effects of intervention, the examination of the wrist and hand for the manipulative physiotherapist will have to take into consideration the points outlined below.
Origin o the s ymptoms The therapist needs to determine whether the symptoms are due to impairment of the structures in the hand or are being referred or generated from more remote sources. By using larger than normal body charts for the wrist and hand, the precise area of the patient’s symptoms can be documented. In such cases a clear relationship between the patient’s pain (symptom) and a known anatomical structure (joint, nerve, muscle/ tendon) may become evident. The description of paraesthesia may reveal, for example, that it is in the cutaneous distribution of the median nerve, and therefore carpal tunnel syndrome may be a more favoured hypothesis than a C5 or C6 nerve root lesion.
Finding cons is tency in unctional demons trations There are an in nite variety of positions in which the wrist and hand can function. This makes consistency in the repeated measurement of functional demonstrations challenging. It is therefore essential to use functional demonstrations to identify the movement directions which make up the impairment. In this way a relevant and detailed model of establishing articular movement impairment can be developed. For example, a patient may complain of wrist pain upon opening a jam jar. O n analysis of the functional movement concerned it can be established that pronation of the wrist and hand is the painful movement. Through differentiation of this painful movement, it will be possible to establish whether the inferior radioulnar joint, radiocarpal, intercarpal or metacarpophalangeal joint is the source of the pain. If the radiocarpal joint is the 325
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source, further differentiation will establish whether it is movement between the scaphoid, lunate or triquetral bones and the radius or radius brocartilaginous disc which is painful. In this way a specically directed mobilization technique is more likely to in uence the joint signs. But it could also be observed that this local pain on the wrist in pronation is increased when the elbow is in extension. Further differentiation using the scapular/ thoracic depression or contra-lateral cervical lateral exion will help to nd a peripheral neurogenic participation and will determine if treatment should be applied in the hand or in the cervical spine or whether the therapist should look for other adverse mechanical interface on the course of the nerve. Another example could be a patient’s activity limitations of non-prehensile function, being unable to fully extend the hand (e.g. when waving). Pain and stiffness across the back of the wrist would suggest a local impairment. Firstly, differentiation would allow the therapist to differentiate between muscular or tendinous, neural and articular origins of the symptoms. Secondly, differentiation would also indicate which further tests are required to determine whether the origin is radiocarpal, intercarpal or carpometacarpal.
Def ning the dominant pain mechanis m Re ecting the history of manual therapy in the last decades, the last two points concerning the origin of the symptoms have been purely tissue related. With hand disorders, it is postulated epidemiologically that pain is the number one reason for consulting a health care practitioner. H owever, as outlined in the introduction to this chapter, it is evident that pain perception should be considered within a more biopsychosocial context. An increased mechanosensitivity, due to mechanical and/ or chemical processes, may also in uence joints and soft tissue pathologies of the hand. The clinical reasoning process should integrate the different pain mechanisms, which are always present in different combinations and are constantly evolving, dynamically changing and switching in importance: A painful and debilitating musculoskeletal condition is mostly a combination of three mechanisms: input, output and processing. 326
Inp ut 1. N ociceptive pain: recent onset symptoms which correspond to a traumatic or injurious event, normally accompanied by the cardinal symptoms of in ammation, such as swelling, heat, redness and signs of sympathetic activity (e.g. sweating), which brings us immediately to the next category – output (see below). 2. Peripheral neurogenic mechanisms: not only paraesthesia or atrophy suggest a pathological process in the nerve, but also factors of a vascular, mechanical (stretching, compression) or systemic nature. All will increase the chemical or mechanical sensitivity of the nerve and implicate it as the source of pain or movement dysfunction. The hypothesis of double crush, as described by Upton & McComas (1973) (of 115 patients with carpal tunnel syndrome, 81 had a cervical origin), is particularly relevant for the upper extremity with canal syndrome or entrapment neuropathy. Mumenthaler (1979) found that of 4958 carpal tunnel operations 9% of patients had a painful shoulder and Narakas (1990) found that of 1916 carpal tunnel operations 26% had a painful shoulder.
Outp ut Sympathetic involvement is obvious in complex regional pain syndrome (CRPS) patients (sensory, motor and vegetative dysfunctions). It is sometimes a bit more tricky to nd its continuous involvement in generating and maintaining all kind of pain, in particular sympathetically maintained pain (SMP). Swelling, altered blood ow, sweating and trophic changes in the skin or nails are the usual signs conrming neurovegetative participation. The T4 syndrome described by Maitland et al. (2001) is another frequent situation involving symptoms of autonomic origin, distributed in the whole hand or arm, outside the dermatomes but in the sudotomes (Jeangros 2011).
P roc e s s ing Central sensitization processing occurs in chronic peripheral neuropathies, high input of action potential or injuries to other structures. As already mentioned, it also depends on the condition of the sensitivity of the CNS, which is altered by affective and cognitive dimension (G ifford 1998).
In tro d u c tio n
Deciding the normal range or ideal range or wris t and hand movement (Fig. 6.1) Kapandji (1982) has suggested that the following ranges of movement are considered as normal average values for the wrist and hand: • Wrist exion and extension 85° each (movement taking place primarily at the radiocarpal and midcarpal articulations) • Wrist radial deviation 15°, wrist ulnar deviation 45° (movement taking place primarily at the radiocarpal joint with accompanying movement at the radioulnar, intercarpal and carpometacarpal joints)
• Wrist pronation 85°, supination 90° (movement taking place primarily at the inferior and superior radioulnar joints, accompanied by rotation at the radiocarpal, midcarpal and carpometacarpal joints). The carpal bones can be described in terms of their rows for examination, differentiation and localization of treatment (Fig. 6.2): the proximal row of carpal bones consists of the scaphoid, lunate, triquetrum and pisiform; the distal row of carpal bones consists of the trapezium, trapezoid, capitate and hamate. These rows therefore are components of the radiocarpal, midcarpal and carpometacarpal joints. The carpal bones can also be described in terms of pillars (Fig. 6.3): the lateral pillar consists of the
Fig ure 6.1 • A The carpal and metacarpal bones of the left hand; B palmar aspect; C dorsal aspect. B and C reproduced from Williams and Warwick 1973, with permission.
Capitate Hamate Trapezium Trapezoid Scaphoid Lunate Triquetrum Pisiform
A 2nd
3rd
3rd 4th
4th 5th
2nd
5th
1st
1st Metacarpal bones
Trapezoid
Styloid process
Capitate Hook of hamate
Trapezium
Pisiform
Scaphoid Lunate
Trapezoid
Hamate
Trapezium
Triquetrum
Triquetrum Capitate
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Metacarpal bones
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Articulate with radius
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The metacarpophalangeal (MCP) joints can ex on average to 90° (similar to the interphalangeal (IP) joints) and can be passively rotated by 60°. The sequence for examination and treatment of the MCP and IP joints is described in detail on pages 363–369. A good working knowledge of surface anatomy (H oppenfeld 1976, Kesson & Atkins 1998) will enhance the clinician’s accuracy in localization and application of forces during movement analysis of the wrist and hand. Carpometacarpal Midcarpal Radiocarpal Inferior radioulnar
Fig ure 6.2 • Rows of carpal bones.
scaphoid and trapezium or trapezoid, the central pillar consists of the lunate and capitate and the medial pillar consists of the triquetrum, pisiform and hamate. The value of this is that, ideally, the mobility within the central pillar should be greater than the medial and lateral pillars when individual carpal mobility is tested (Kapandji 1982). The intercarpal joints and intermetacarpal joints also exhibit a degree of hollowing and attening which, in this text, is described as horizontal exion and extension.
Subje c tive e xaminatio n (C/O) Procedural and interactive reasoning allow the therapist to build hypotheses to identify the problem. Information from the subjective examination of the patient with wrist and hand symptoms will help to establish the kind of disorder being presented, the source and dominating pain mechanism of the patient’s symptoms and the degree to which daily activity is limited by the severity, irritability and nature of the disorder. Information about the history of the symptoms will help to establish the nature of the onset, the directions and degree of injuring forces and the present stage of the disorder’s natural history. Special questions will establish any precautions and contraindications to treatment and whether there are any intrinsic or extrinsic predisposing factors or barriers to an ideal rate of recovery.
Kind o dis order: es tablis hing the patient’s main problem(s ) • A good working knowledge of surface anatomy
Lateral pillar Central pillar Medial pillar
Fig ure 6.3 • Pillars of carpal bones. 328
of the wrist and hand will help to team up the patient’s wrist and hand symptoms with a recognizable joint, peripheral nerve or muscle. • Activity limitations which include the prehensile or non-prehensile functions of the wrist and hand will strengthen the hypotheses suggesting a local disorder. • A strong relationship between the symptoms and mechanical trauma or stress to the wrist and hand is what the clinician should expect. Essentially, the patient would be expected to complain of pain, stiffness, swelling, loss of function, loss of feeling and weakness of the wrist and hand.
S u b je c tive e xa m in a tio n (C / O )
Areas o s ymptoms As discussed earlier in this chapter, a large or ‘real size’ wrist and hand chart should be used so that the precise area of the patient’s symptoms can be represented more accurately (Fig. 6.4). In this way the area which the patient describes as being painful is often diagnostic in itself. A band of pain across the wrist is common in radiocarpal joint disorders; inferior radioulnar joint pain is usually felt locally and deep. Any referred pain is usually felt to spread
from the joint towards the elbow. Pain arising from any of the intercarpal joints is always felt locally, although it may radiate out from a central point of the disordered joint. Pain from the intermetacarpal joints will be felt locally at their bases and over the joint. Pain and swelling over the abductor pollicis longus or extensor pollicis brevis tendons indicates a diagnosis of de Q uervain’s tenosynovitis. Paraesthesia of the thumb, index, ring and half the middle nger is a common presentation in carpal tunnel syndrome (Figs 6.5 and 6.6). Right hand Sharp deep, 3 intermittent (scaphoid/lunate)
2 Sharp deep, occasional (inferior radioulnar) 1 Band ache deep, intermittent (radiocarpal)
A
B
Fig ure 6.4 • A Hand symptoms-body chart. B Right hand: areas of symptoms.
Extensor pollicis longus
Fig ure 6.5 • Extensor pollicis longus.
Fig ure 6.6 • Cutaneous supply of the median nerve in the hand. 329
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A large diffusion of symptoms in the whole hand, occasionally accompanied by heaviness and tiredness of the whole hand, forearm, or whole arm, may lead to suspect a TO S (thoracic outlet syndrome) or a T4 syndrome (Maitland et al. 2001, Jeangros, 2011) with the output as the dominant pain mechanism.
Behaviour o s ymptoms If activities increasing the symptoms are numerous and easy to nd, it is helpful to establish the common characteristics of the mechanical disorders, which also con rm a dominant input mechanism of pain and support our hypotheses about the treatment and prognosis. If the wrist and hand are the source of the patient’s symptoms, hand functions will be compromised or restricted by pain, stiffness, protective spasm or other associated signs such as weakness, pain inhibition or loss of feeling. Prehensile functions which may be compromised include forearm twisting (pronation, supination), wrist exion, extension, ulnar and radial deviation, the function of opposition and manipulative or gripping activities; non-prehensile functions which may be compromised include pushing, pulling or weightbearing activities. The stage of the disorder and the severity and irritability of the symptoms will determine the degree of impairment experienced by the patient. For example, a patient who has a one-week history of a badly sprained wrist will use the hand less than someone with stiffness 12 weeks after a Colles’ fracture. As already seen in the introduction, the loss of hand function may also impact on the cognitive and emotional dimensions of the patient’s experience of impairment. As an important sensory and communication organ, the impaired hand will affect many aspects of the patient’s daily life. Night-time is usually a time of relief from mechanical nociceptive symptoms. H owever, patients with peripheral neurogenic mechanisms often suffer more from their symptoms at night. With osteoarthritic or degenerative disorders, morning stiffness would be expected, as would morning soreness with in ammatory components.
His tory (pres ent and pas t) Information from the recent and past history of the patient symptoms will provide valuable evidence 330
about the sensitized status of the central nervous system on the one hand, and the bio-psychosocial impact of this sensitization on the other. Such information helps to support the clinical diagnosis and prognosis O ften, the history of the patient’s symptoms will correspond to the different recognizable patterns as described by Corrigan & Maitland (1983):
• Spontanous insidious onset corresponds mostly to degenerative rheumathological disease such as arthritis or tendinopathy through overuse or repeated friction • Peripheral neurogenic mechanisms may also be considered, but are more dif cult to detect, especially if they are not accompanied by paraesthesia or atrophy • Traumatic events, fractures (Colles’ fracture, scaphoid necrosis, etc.), intra- and periarticular, soft tissue (tendon, ligament, etc.) injuries should be considered.
Medical s creening ques tions The main area of concern with wrist and hand symptoms is whether any neurological compromise is taking place or could be effected by physical examination and treatment. Vascular or metabolic disorders may also present with symptoms in the hands. Special attention should be paid to scaphoid necrosis, particularly in the absence of X-rays.
Planning the phys ic al e xaminatio n (P/E) When planning the physical examination, the therapist must rst determine which structure should be examined on day one. With a hypothesis of peripheral neurogenic mechanisms, the cervical spine may be included in the examination and treatment on day one. In such cases, it is important to examine the neurological conduction status of the limb (sensation, re exes and motor power), something which is not always necessary as part of the physical examination of the wrist and hand. Before examining the cervical spine, it is useful to see an active movement of the hand or to look at a functional demonstration involving the hand. The reassessment of the hand movement reproducing the symptoms, or being a comparable sign, could then show the in uence of the treatment of the spine on the hand.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
If the hypothesis is suggestive of a nociceptive origin of pain, the focus will be directed onto the structure that is most affected, local or remote: joint, tendons, muscles or ligaments. With a hypothesis of output pain mechanisms, it may be necessary to decide to treat the thoracic spine at the rst treatment, either by mobilization or manipulation with the aim of calming down the sensitivity of the sympathetic trunk. This treatment could also be performed in a sympathetic slump position (Jeangros 2011). A decision should be made whether to respect irritability or whether it will be dif cult to nd the symptoms and therefore if the hand should be treated gently or with vigour. In some instances,
such as in cases of rheumatoid arthritis, more forceful mobilization is contraindicated. In such cases management should be directed towards ergonomic issues, exercise and automobilization and stabilization strategies.
Phys ical examination (P/E) (Boxes 6.1-6.9) Ob s e rva tion • The observation begins when the patient enters the room and shakes hands. At this point the therapist is already evaluating the patient’s willingness to move and use the hand. The
Box 6.1 Wrist and hand complex A. Move to pain or move to lim it B. Chronic – minor wris t or hand s ymptoms Mandatory pas s ive movement tes t, when chronic s ymptoms occupy any part o the area rom the lower third o the radius and ulna to the mid-metacarpals (thumb excluded). S upine: • Flexion and extens ion • Supination and pronation (through metacarpals ) • Radial and ulnar deviation • AP/PA movement • HF and HE • Longitudinal caudad and cephalad Tes t movements begin as IV− with obs ervation or pain res pons e. I pain ree, adequate overpres s ure is applied
until pain is provoked or the movement is judged ‘clear’. When a pos itive pain res pons e is provoked, that tes t movement may need to be di erentiated to determine the s pecif c joint at ault, and/or other movements may need to be tes ted s o as to either exclude or incriminate other joints as contributing to the s ymptoms . I all tes t movements appear ‘clear’ at f rs t examination, they s hould be repeated more s trongly. I s till ‘clear’, they may prove pos itive when repeated at the next cons ultation. C. Proving the wris t or hand is una ected • F and E (f ngers to wris t) • Supination and pronation • Wris t deviations • ceph, caud
Reproduced by kind permission from Maitland (1992).
Box 6.2 Physical examination of the inferior radioulnar joint The routine examination o this joint mus t als o include examination o the wris t, as s upination and pronation als o occur as acces s ory movements o the wris t joint.
•
Obs e rvatio n
Routinely • Wris t Ab, Ad (F and E) • Supination, pronation • Note range, pain
*Functional demons tration/tes ts •
Their demons tration o their unctional movements a ected by their dis order
Di erentiation o their demons trated unctional movement(s )
Brie f apprais al Ac tive mo ve me nts (mo ve to p a in o r mo ve to lim it)
331
Box 6.2—cont’d Is o me tric te s ts Othe r s truc ture s in ‘plan’ • • •
Thoracic outlet Entrapment neuropathy Tendon s heaths
Pas s ive mo ve me nts Physiological m ovem ents Routinely • Sup and Pron Note range, pain, res is tance, s pas m and behaviour Accessory m ovem ents As applicable 1. , a. in neutral (als o ) b. at limit o pronation c. at limit o s upination
2. Sup or Pron with compres s ion 3. Sup and Pron di erentiating or wris t Note range, pain, res is tance, s pas m and behaviour 4. Slump tes t 5. Di erentiation tes ts 6. ULNT
P a lp a tion + When ‘comparable s igns ’ ill-def ned, reas s es s ‘injuring movement’ Check cas e records etc. Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission from Maitland (1992).
Box 6.3 Physical examination of the wrist joint The routine examination o this joint mus t include the in erior radioulnar joint and intercarpal joints .
Obs e rvatio n *Functional demons tration/tes ts • •
Their demons tration o their unctional movements a ected by their dis order Di erentiation o their demons trated unctional movement(s )
Brie f apprais al Ac tive mo ve me nts (mo ve to p a in o r mo ve to lim it) Routinely • F, E, Ab, Ad, Sup, Pron • Note range, pain (repeated and rapid) • Clenching f s t
Is o me tric te s ts Othe r s truc ture s in ‘plan’ As applicable • Full active res is ted movement through range or ‘s heaths ’ • Thoracic outlet • Entrapment neuropathy Reproduced by kind permission from Maitland (1992).
Pas s ive mo ve me nts Physiological m ovem ents Routinely • F, E, radial and ulnar deviation, Sup and Pron • Note range, pain, res is tance, s pas m and behaviour. All without and with compres s ion as applicable Accessory m ovem ents Routinely: , , ceph and caud As applicable 1. F and E di erentiating 2. Sup and Pron di erentiating 3. Menis cus 4. Pis i orm 5. Wris t , , in s upination, neutral and pronation and in varying pos itions o exion and extens ion 6. Slump tes t 7. Di erentiation tes ts 8. ULNT
P a lp a tion •
Include tendon s heaths and ‘anatomical s nu box’ as applicable • + When ‘comparable s igns ’ ill-def ned, reas s es s ‘injuring movement’ Check cas e records etc. Highlight m ain f ndings with asterisks Ins tructions to patient
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Box 6.4 Physical examination of the intercarpal joints The routine examination o thes e joints mus t als o include examination o the wris t joint, carpometacarpal (C/MC) joints and pis i orm movements .**
Obs e rvatio n *Functional demons tration/tes ts • •
Their demons tration o their unctional movements a ected by their dis order Di erentiation o their demons trated unctional movement(s )
Brie f apprais al Ac tive mo ve me nts (mo ve to p a in o r mo ve to lim it) Is o me tric te s ts Othe r s truc ture s in ‘plan’ • • •
Add ull active res is ted movement through range or ‘s heaths ’ Thoracic outlet Entrapment neuropathy
Pas s ive mo ve me nts Physiological m ovem ents Routinely 1. Wris t F, E, Ab, Ad, Sup, Pron 2. Midcarpal F and E 3. Di erentiating F and E 4. Individual carpometacarpal (C/MC) F and E
Note range, pain, res is tance, s pas m and behaviour Accessory m ovem ents Routinely 1. and (varying angles and points o contact). (i.e. gliding o each carpal bone on adjacent carpal bone) 2. HF and HE o carpus 3. **Pis i orm, without compres s ion and with compres s ion, , ceph and caud, dis traction 4. C/MC joints a. and (varying angles and points o contact) b. o metacarpals on carpus , with and without abduction and adduction c. and metacarpals Note range, pain, res is tance, s pas m and behaviour 5. Slump tes ts 6. Di erentiation tes ts 7. ULNT
P a lp a tion • •
Include tendon s heaths + When ‘comparable s igns ’ ill-def ned, reas s es s ‘injuring movement’ Check cas e records etc. Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission from Maitland (1992).
therapist will also become aware of the strength of the patient’s grip. • Inspection of the cardinal signs – colour changes of the skin, in ammation, deformity, trophic changes (skin, nails, hair), other circulatory changes, as well as general dexterity.
Func tiona l d e mons tra tion • Let the patient demonstrate the activity reproducing their pain or producing a degree of discomfort which is considered as abnormal, limited or impairing. • Look for alignment faults with grip, including the ability to fully oppose the thumb and the range of nger exion. • Look for gripping with the wrist in exion or gripping with the wrist deviating (usually radial
because of overpull of extensor carpi radialis brevis). • Analyze and record the ranges of movement, the symptom response and the quality of movement. • Pain increased by weight-bearing activities could con rm a more intra-articular participation. • For pain arising from the inferior radioulnar joint the functional demonstration may involve the action of turning on a tap. The point at which the pain comes on with supination is determined and in this position the ulna can be moved further into the range to determine any increase in pain.
Ac tive move me nts of whole ha nd • Active movements of the whole hand with grade III+ overpressure if necessary, recording 333
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Manag e me nt o f wris t and hand dis o rde rs
Box 6.5 Physical examination of the carpometacarpal joints The routine examination of thes e joints mus t include examination of intercarpal joints and proximal and dis tal intermetacarpal joints and s paces .
Note range, pain, res is tance, s pas m and behaviour Accessory m ovem ents Routinely
Ob s e rva tion
1.
*Functional demons tration/tes ts
ceph, caud), 2. and 3. Abduction and adduction 4. Combining (2) with (3)
• •
Their demons tration of their functional movements affected by their dis order Differentiation of their demons trated functional movement(s )
5.
Brie f a p p ra is a l Ac tive move me nts (move to p a in or move to lim it)
and
(varying angles , medial, lateral,
and of metacarpals All with and without compres s ion Note range, pain, res is tance, s pas m and behaviour As applicable
Othe r s truc ture s in ‘p la n’
1. Slump tes t 2. Differentiation tes ts 3. ULNT
•
P a lp a tion
Is ome tric te s ts
• •
Full range active or res is ted wris t and nger F for s heaths Thoracic outlet Entrapment neuropathy
P a s s ive move me nts Physiological m ovem ents Routinely 1. Individual C/MC F and E 2. HF and HE of carpus 3. HF and HE of metacarpals
Include tendon s heaths + When ‘comparable s igns ’ ill-de ned, reas s es s ‘injuring movement’ Check cas e records etc. Highlight m ain ndings with asterisks Ins tructions to patient
and differentiating
Reproduced by kind permission from Maitland (1992).
Box 6.6 Physical examination of intermetacarpal movement Obs e rvatio n *Functional demons tration/tes ts • •
Their demons tration o their unctional movements a ected by their dis order Di erentiation o their demons trated unctional movement(s )
Brie f apprais al Ac tive mo ve me nts (mo ve to p a in o r mo ve to lim it) Is o me tric te s ts Othe r s truc ture s in ‘plan’ •
Full active res is ted movement through range or ‘s heaths ’
334
• •
Thoracic outlet Entrapment neuropathy
Pas s ive mo ve me nts Physiological m ovem ents Routinely • HF and HE o metacarpals (on bas es and heads ) Note range, pain, res is tance, s pas m and behaviour As applicable 1. Slump tes ts 2. Di erentiation tes ts 3. ULNT
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Box 6.6—cont’d Accessory m ovem ents Routinely 1. and o each metacarpal in relation to its neighbour (bas es and heads ) 2. Individual HF or HE (bas es and heads ) Note range, res is tance, pain, s pas m and behaviour
P a lp a tion • •
Include tendon s heaths + When ‘comparable s igns ’ ill-def ned, reas s es s ‘injuring movement’ Check cas e records etc. Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission from Maitland (1992).
Box 6.7 Physical examination of the metacarpophalangeal and interphalangeal joints Obs e rvatio n *Functional demons tration/tes ts • •
Their demons tration o their unctional movements a ected by their dis order Di erentiation o their demons trated unctional movement(s )
Brie f apprais al Ac tive mo ve me nts (mo ve to p a in o r mo ve to lim it) Routinely • F, E, s preading; f s t or grip Note range and pain, repeated and rapid
Is o me tric te s ts Othe r s truc ture s in ‘plan’ As applicable • Full active res is ted movements through range or ‘s heaths ’ • J oint res triction, c. . mus cle or tendon res triction • Thoracic outlet • Entrapment neuropathy
Pas s ive mo ve me nts
Note range, pain, res is tance, s pas m and behaviour As applicable • J oint res triction, c. . mus cle or tendon res triction Accessory m ovem ents Routinely 1. ceph and caud, Ab, Ad, , , , , , 2. The above in di erent pos itions o other phys iological ranges As applicable 1. Same movements under compres s ion 2. Ab, with and 3. Ad, with and 4. Slump tes ts 5. Di erentiation tes ts 6. ULNT
P a lp a tion • •
Include tendon s heaths + When ‘comparable s igns ’ ill-def ned, reas s es s ‘injuring movement’ Check cas e records etc. Highlight m ain f ndings with asterisks Ins tructions to patient
Physiological m ovem ents Routinely • F, E Reproduced by kind permission from Maitland (1992).
335
C H AP TE R 6
Manag e me nt o f wris t and hand dis o rde rs
Box 6.8 Physical examination of the carpometacarpal joint of thumb The routine examination o this joint mus t include the adjacent intercarpal joints and wris t.
Obs e rvatio n *Functional demons tration/tes ts • •
Their demons tration o their unctional movements a ected by their dis order Di erentiation o their demons trated unctional movement(s )
Brie f apprais al Ac tive mo ve me nts (mo ve to p a in o r mo ve to lim it) •
Add active movements o thumb including gripping and f s t
Is o me tric te s ts Othe r s truc ture s in ‘plan’ • • •
Full active res is ted movements through range or ‘s heaths ’ J oint res triction, c. . mus cle or tendon res triction Entrapment neuropathy
Pas s ive mo ve me nts Physiological m ovem ents Routinely 1. Thumb F, E, Ab, Ad 2. Di erentiating F, E, Ab, Ad Rotn and oppos ition 3. HF and HE o carpus
Note range, pain, res is tance, s pas m and behaviour Accessory m ovem ents Routinely 1. and o f rs t metacarpal on trapezium 2. and agains t metacarpal on carpus , with and without abduction and adduction, with and without compres s ion 3. and and o metacarpal, with and without compres s ion 4. adjacent intercarpal and 1s t C/MC joint Note range, pain, res is tance, s pas m and behaviour As applicable 1. Intercarpal tes ts 2. C/MC with E 3. Slump tes ts 4. Di erentiation tes ts 5. ULNT
P a lp a tion • •
Include tendon s heaths + When ‘comparable s igns ’ ill-def ned, reas s es s ‘injuring movement’ Check cas e records etc. Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission from Maitland (1992).
Box 6.9 Physical examination of the composite wrist or hand Obs e rvatio n *Functional demons tration/tes ts • •
Their demons tration o their unctional movements a ected by their dis order Di erentiation o their demons trated unctional movement(s )
Brie f apprais al Ac tive mo ve me nts (mo ve to p a in o r mo ve to lim it) • • •
Clench f s t and tes t grip F, E, Ab and Ad o wris t Sup and Pron
336
Is o me tric te s ts Othe r s truc ture s in ‘plan’ Pas s ive mo ve me nts As required Whole hand 1. F and E 2. Radial and ulnar deviation 3. Sup and Pron 4. ceph and caud 5. HF and HE 6. Pis i orm 7. , , in di erent pos itions o wris t Sup, Pron, F and E
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Box 6.9—cont’d 8. Sheaths 9. Tendon length and unction 10. Menis cus Di erentiating as required 1. F and E a. radiocarpal b. midcarpal c. carpometacarpal 2. Radial and ulnar deviation a. radiocarpal b. midcarpal c. carpometacarpal 3. Supination and pronation a. radiocarpal b. in erior R/U joint 4. caud and ceph a. radiocarpal b. intercarpal c. carpometacarpal
5. HF and HE a. intercarpal b. carpometacarpal c. intermetacarpal Other test m ovem ents 1. , , , , , ( rom in erior R/U to heads o metacarpals ) 2. Slump tes ts 3. ULNT
P a lp a tion •
+ When ‘comparable s igns ’ ill-def ned, reas s es s ‘injuring movement’ Check cas e records etc. Highlight m ain f ndings with asterisks Ins tructions to patient
Reproduced by kind permission from Maitland (1992).
range, symptom response and quality of movement (palmar exion 85°, dorsal extension 85°, ulnar adduction 45°, radial abduction 15°) and brief appraisal tests should also include, pronation, supination, horizontal exion and horizontal extension.
•
I neces s ary tes ts Is ome tric te s ts (grip s tre ngth te s t) • Indication for using these ‘if necessary tests’ would be, on the one hand, to recognize the typical pattern (for example, pain after repeated movement and stiffness after rest) or localization of a muscle or tendon (knowing that most of the strains occur at the musculotendinous junction). • O n the other hand, as it is nearly impossible to mobilize a joint of the wrist without having the ngers of the therapist affecting a tendon, it seems important to differentiate rst if the pain is coming from a tendon or another structure. • O ther indications for using isometric tests would be a diagnosis of de Q uervain’s disease, Dupuytren’s contracture, a past history of overuse (secretary with mouse), a recent
•
•
•
overstretching, a traumatic event or a muscle strain con rmed by an MRI or not. Finkelstein’s test is, for example, used when considering dysfunction of the abductor pollicis longus and the extensor pollicis brevis suggesting a de Q uervain tendinopathy: exion (and adduction) of the thumb combined with a strong ulnar deviation. This test is very similar to the neurodynamic test ULNT 2b (Butler 1991) for testing the radial nerve, and will need further differentiation with elbow extension, scapular elevation or lateral exion of the cervical spine. Symptoms are seldom related to a single structure. Most of the muscles and tendons in the hand cross more than one or two joints and perform eccentric contraction. This means the hand contains a greater proportion of mobilizing rather than stabilizing muscles. Isometric tests are rst performed in neutral and then in the functional position. The localization of symptoms and direct palpation (or deep friction) can help to differentiate beween muscles and tendons. Tendons are tested by full stretching, maximal elongation. Further differentiation between the tendon and the sheath of the tendon 337
C H AP TE R 6
Manag e me nt o f wris t and hand dis o rde rs
(tenosynovitis) can be made by compressing the tendon at the painful spot and letting the tendon move through range. • The grip strength test can be used for re-evaluation, but is not pathognomonic.
Ne urologic a l e xa mina tion If symptoms follow a dermatomal distribution (Fig. 6.7) or if there is a history of cervical spine involvement then a thorough neurological examination of the upper extremity is necessary. In this case, a peripheral neurological examination of the sensitivity (light touch and pinprick, re exes and motor power will be assessed) (Fig. 6.8).
Ne urod yna mic te s ts Neurodynamic tests are obligatory where there is a need to differentiate between structures causing symptoms in the upper extremity. The distribution of symptoms will determine whether there is a need to use the ULNT1 (median bias), ULNT 2b (radial bias) or ULNT 3 (ulnar bias) (Butler 1991).
In s up ine lying Inspection and palpation • Identi cation of surface anatomy landmarks (H oppenfeld 1976).
• Identi cation of signs of movement impairment (temperature changes, excessive sweating, soft tissue changes including swelling and soft tissue thickening, bony abnormalities such as exostosis). • Palpation of the median, ulnar and radial nerves around the wrist and hand for mechanosensitivity, symptom reproduction and signs of swelling or thickening (Fig. 6.9). • Palpate tendons and tendon sheaths where tenosynovitis may be evident (abductor pollicis longus and extensor pollicis brevis in particular). • Brachial and radial pulses to check for circulatory viability.
Diffe re ntia tion of move me nts re p rod uc ing p a in • Pronation and supination: differentiate between inferior radioulnar, radiocarpal, midcarpal and carpometacarpal (Figs 6.10–6.15). • Flexion and extension: differentiate radiocarpal and midcarpal (see Figs 6.23–6.28). • Radial and ulnar deviation: differentiate inferior radioulnar, radiocarpal and midcarpal (see Figs 6.29–6.32). • H orizontal exion and extension: differentiate between proximal and distal carpal rows and intermetacarpal joints (see Figs 6.37–6.38).
C6
C8
C7 C8 C8
C6
C6
C7
A
B
Fig ure 6.7 • Dermatomes. Reproduced from Williams and Warwick 1973, with permission. 338
Fig ure 6.8 • Cutanous peripheral nerve supply. After Putz and Pabst 2006.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
• Midcarpal joint: exion, extension, horizontal Ulnar nerve Median nerve Radial nerve (superficial branch)
Muscular branch of median nerve
Superficial branch of ulnar nerve Dorsal branch of ulnar nerve Digital branch of ulnar nerve
Digital branch of median nerve
Fig ure 6.9 • Super cial nerves.
P a s s ive move me nts wris t a nd ha nd – e xa mina tion a nd tre a tme nt te c hniq ue s Whole hand movements, differentiating rows: • Inferior radioulnar joint: pronation, supination, anteroposterior or posteroanterior movement, longitudinal movement cephalad and caudad, compression, movements under compression. • Radiocarpal joint: exion, extension, radial deviation, ulnar deviation, medial rotation, lateral rotation, anteroposterior/ posteroanterior movements, transverse movement medially, transverse movement laterally, horizontal exion, horizontal extension, compression, distraction, movements under compression/ distraction.
exion, horizontal extension. • Intercarpal movements: anteroposterior/ posteroanterior movements of individual bones or over the joint line, with inclinations. • Intermetacarpal joints: anteroposterior or posteroanterior movements, horizontal exion, horizontal extension. • Carpometacarpal, metacarpophalangeal, interphalangeal joints: exion, extension, abduction, adduction, medial rotation, lateral rotation, anteroposterior or posteroanterior, transverse medial, transverse lateral, compression, distraction, movements under compression or distraction.
Diffe re ntia tion of ra d ia l a nd ulna r d e via tion • Ulnar – see Figures 6.29 and 6.30. • Radial – see Figures 6.31 and 6.32. • Longitudinal caudad/ cephalad of the inferior radioulnar joint – see Figures 5.46 and 6.22. • Localization of forces to radiocarpal, midcarpal and carpometacarpal – see Figures 6.30 and 6.32.
Diffe re ntia tion of horizonta l e xion a nd e xte ns ion • Intercarpal – see Figures 6.37 and 6.38. • Intermetacarpal – see Figure 6.46.
Sup ina tion (Figs 6.16 and 6.17) Method This technique is identical to that described in Chapter 5, see Figures 5.40 and 5.41.
P rona tion (Figs 6.18 and 6.19) Method This technique is identical to that described in Chapter 5, see Figures 5.42 and 5.43.
Infe rior ra d ioulna r joint p os te roa nte rior a nd a nte rop os te rior move me nts (Fig. 6.20) • Direction: The posteroanterior (PA) and anteroposterior (AP) movements are referred to 339
Fig ure 6.11 • Inferior radioulnar and radiocarpal supination.
Fig ure 6.10 • Whole hand supination.
Fig ure 6.12 • Release radiocarpal supination.
Fig ure 6.13 • Release radioulnar supination.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Fig ure 6.14 • Increase radiocarpal supination.
Fig ure 6.15 • Increase radioulnar supination.
as movements of the ulna on the radius because it is easier to stabilize the comparatively large distal end of the radius and produce the movement by pushing the distal end of the ulna. • Symbols: , • Patient starting position: Supine in the middle of the couch with the elbow exed to 90°. The
Fig ure 6.16 • Inferior radioulnar joint: supination grades I–IV.
Fig ure 6.17 • Inferior radioulnar joint: supination grade IV+. 341
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Fig ure 6.19 • Inferior radioulnar joint: pronation, grade IV+.
Application of forces by therapist (method) • A PA movement of the ulna on the radius is
Fig ure 6.18 • Inferior radioulnar joint: pronation.
• • • • • •
AP and PA movements are of the largest amplitude possible with the inferior radioulnar joint positioned midway between pronation and supination. The movements can be produced in any position of pronation and supination. Therapist starting position: Standing by the patient’s right side just beyond the exed elbow, facing the patient’s left shoulder. Localization of forces (position of therapist’s hands). The thumb and index nger of both hands hold the patient’s forearm midway between pronation and supination. The thumb of the left hand posteriorly and the exed index nger anteriorly hold onto the distal end of the radius. The remaining ngers ex to add lateral support to the index nger which makes the main point of contact. The right hand holds the distal end of the ulna with an identical grip. 342
produced by pressure against the posterior surface of the ulna with the therapist’s right thumb and an equal and opposite pressure against the anterior surface of the radius with the left index nger. • An AP movement of the ulna on the radius would be produced by an opposite action.
Fig ure 6.20 • Inferior radioulnar joint: posteroanterior and anteroposterior movements.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Variations in the application of forces • For stronger movement stretching at the limit of supination or pronation the therapist should grasp the radius and ulna more rmly between the thenar eminences rather than just using the thumbs and index ngers. In this way the PA and AP stretching can be performed more strongly at the limit of supination or pronation by a pushing and pulling action of the arms.
Localization of forces (position of therapist’s hands) • Both hands grasp the patient’s right hand. • The thumbs and thenar eminences, pointing
•
Uses
•
• Mainly clinical groups 2 and 3b. • Patients with stiffness or pain and stiffness with
•
pronation or supination. • Postfracture or postimmobilization pain and stiffness in pronation or supination.
•
towards the patient’s ngers, cover the posterior surface of the patient’s wrist meeting in the midline. The ngers reach around to meet anteriorly in the midline. The heel of the left hand cups around the lateral surface of the distal end of the patient’s radius. The heel of the right hand cups around the distal end of the patient’s ulna. Both arms are directed opposite to each other at right angles to the patient’s forearm.
Infe rior ra d ioulna r c omp re s s ion (Fig. 6.21)
Application of forces by therapist (method)
• Direction: Compression of the radius and ulna
by a twisting in opposite directions of the heels of the therapist’s cupped hands, pivoting around stationary ngers and thumbs. • Pronation of the patient’s forearm is produced by pronation of the therapist’s left forearm and supination of the right forearm so that the heels of the therapist’s hands move away from each other. • Supination is produced by supination of the therapist’s left forearm combined with pronation of the right. • A back-and-forth rocking movement between supination and pronation is continued while compression is maintained between the therapist’s two arms.
towards each other at the inferior radioulnar joint. • Symbol: • Patient starting position: Supine in the middle of the couch with the elbow exed to 90° and the forearm in the mid-pronation or midsupination position. • Therapist starting position: Kneeling by the patient’s right side beyond the exed elbow.
• Firstly, supination and pronation are produced
Variations in the application of forces • As a brief appraisal test for the joint, the radius can be compressed strongly against the ulna at the same time as rocking the radius and ulna back and forth against each other. • The same grip can be used to distract or separate the distal ends of the radius and ulna.
Uses • When pain in the inferior radioulnar joint is
Fig ure 6.21 • Inferior radioulnar joint: compression.
aggravated by gripping activities. • When pain is provoked on squeezing the radius and ulna rmly together at the inferior radioulnar joint. 343
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Infe rior ra d ioulna r joint longitud ina l move me nt c a ud a d /c e p ha la d Method This technique is identical to that described for Figure 5.46 (caudad) and Figure 6.22 (cephalad).
Variations in the application of forces These longitudinal movements are described as being longitudinal movement of the radius on the ulna. The reasons for presenting the movement as being that of the radius on the ulna are:
• The ulna is relatively more stable at the elbow • O ne of the best ways of producing this movement is to carry out ulnar deviation of the hand, which pulls the radius in a caudad direction. Cephalad longitudinal movement of the radius on the ulna is produced by radial deviation of the wrist.
Longitudina l movement cepha la d • Emphasis is placed on the exact position of the patient’s hand and the direction of the pressure applied by the therapist’s hand.
• The patient’s hand must be tilted towards radial deviation (abduction) and the therapist should apply contact mainly through the base of the patient’s thenar eminence so that the pressure is in a straight line with the shaft of the radius. • During radial deviation o the patient’s hand there is a cephalad longitudinal movement o the radius in relation to the ulna.
Longitudina l movement ca uda d • The therapist must grasp around the patient’s hand immediately adjacent to the base of the rst metacarpal and the pisiform. • During the movement longitudinally the patient’s wrist should be deviated towards the ulnar side (adduction). • During ulnar deviation o the patient’s wrist there is a caudad longitudinal movement o the radius in relation to the ulna.
Uses • Limited or painful radial and ulnar deviation of the wrist and hand. • Painful restricted longitudinal movement of the radius on the ulna at the inferior radioulnar joint.
Wris t e xion (ge ne ra l) (Fig. 6.23) • Direction: G eneral exion of the wrist and hand. • Symbol: F. • Patient starting position: Supine in the middle of the plinth with the elbow exed to 90° and midway between pronation and supination. • Therapist starting position: Standing by the patient’s right side beyond the exed elbow.
Localization of forces (position of therapist’s hands) • The right hand grasps around the medial border
Fig ure 6.22 • Superior radioulnar joint: longitudinal movement cephalad. 344
of the patient’s right hand. • The thumb is placed against the dorsum of the patient’s metacarpals. • The ngers are placed in the palm of the patient’s hand. • The left hand stabilizes the patient’s forearm midway between supination and pronation immediately proximal to the carpus.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Fig ure 6.23 • Wrist exion (general).
Fig ure 6.24 • Radiocarpal exion.
Application of forces by therapist (method) • Starting midway between exion and extension the therapist’s thumb exes the patient’s wrist and hand to the limit of its range; the therapist’s ngers then return the patient’s wrist to its starting position. • The therapist’s index nger is positioned near to the patient’s metacarpophalangeal joints so as to control the return movement.
• Patient starting position: Supine, lying in the
Uses
• Both the therapist’s hands hold the patient’s
middle of the couch, forearm and wrist supinated. • Therapist starting position: Standing by the patient’s right hip facing the right shoulder.
Localization of forces (position of therapist’s hands)
• As examination of wrist exion with the • • • •
addition of overpressure if necessary. As a general mobilization of wrist and hand exion. Recovery of exion after a Colles’ fracture. As a through-range mobilization for patients with osteoarthritis of the wrist. As a neurodynamic mobilization technique in the ULNPT 2b position (radial nerve entrapment).
• • • •
Ra d ioc a rp a l e xion (Fig. 6.24) • Direction: Flexion localized to the radiocarpal joint only. • Symbol: Radiocarpal F.
•
supinated and extended arm at the wrist. Both thumbs point proximally on the anterior surface of the proximal row of the carpal bones. The ngers are placed across the back of the carpus. The exed index ngers form the main point of contact against the proximal row of the carpal bones posteriorly. The index ngers and thumbs grasp immediately opposite each other mainly around the scaphoid and lunate but also including the triquetrum. The thumbs make contact through the base of their terminal phalanges rather than their tips. 345
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Application of forces by therapist (method) • From a position midway between exion and extension, the patient’s wrist is moved downwards towards the oor while the carpus, held rmly between the therapist’s index ngers and thumbs, is exed on the radius and ulna. While performing this movement the carpus must be held rmly.
Variations in the application of forces • The point of contact of the thumbs can be adjusted to in uence movement more at the scaphoid, lunate or triquetrum. • The exion can also be repeated in varying positions of radial or ulnar deviation.
Uses • As a localized mobilization of the radiocarpal joint. • To mobilize the radiocarpal joint after scaphoid fracture. • Combined with horizontal extension to assist in the rehabilitation of patients with carpal tunnel syndrome. • As part of the process of differentiating wrist pain coming from the radiocarpal or midcarpal joints.
Mid c a rp a l e xion (Fig. 6.25) • Direction: Flexion localized to the midcarpal joint, i.e. between the proximal and distal rows of the carpal bones. • Symbol: Midcarpal F. • Patient starting position: Supine in the middle of the couch with the arm and wrist supinated. • Therapist starting position: Standing by the patient’s right side facing the right shoulder.
Localization of forces (position of therapist’s hands) • The tips of both thumbs are placed over the anterior surface of the distal carpal row (i.e. the trapezium, trapezoid, capitate and hamate). • The index ngers, pointing towards each other and reinforced by the middle ngers overlie the posterior surface of the proximal carpal bones (i.e. scaphoid, lunate, triquetrum and pisiform). 346
Fig ure 6.25 • Midcarpal exion.
Application of forces by therapist (method) • Flexion at the midcarpal joint is produced by a tilting action of exion of the patient’s hand pivoting through the thumb tips which apply pressure to the proximal carpal row anteriorly. • Counterpressure is applied to the proximal carpal row posteriorly by the index ngers. • If performed correctly there should be no radiocarpal or carpometacarpal movement.
Summary • Thumbs against the distal row anteriorly. • Index ngers against the proximal row posteriorly.
Uses • Localization of exion to the midcarpal joint. • Differentiation of pain originating from the radiocarpal or midcarpal joints.
Wris t e xte ns ion (ge ne ra l) (Fig. 6.26) • Direction: G eneral extension of the wrist and hand. • Symbol: E. • Patient starting position: Supine in the middle of the couch with the elbow exed to 90° and midway between pronation and supination. • Therapist starting position: Standing by the patient’s right side beyond the exed elbow.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Localization of forces (position of therapist’s hands) • The right hand grasps around the medial border of the patient’s right wrist. • The thumb is placed against the dorsum of the patient’s metacarpals. • The ngers are placed in the palm of the patient’s hand. • The left hand stabilizes the patient’s forearm midway between supination and pronation immediately proximal to the carpus.
Application of forces by therapist (method) • Starting midway between exion and extension the therapist’s ngers extend the patient’s wrist and hand to the limit of its range; the therapist’s thumb then returns the patient’s wrist to its starting position.
• As a through-range mobilization for patients with osteoarthritis of the wrist. • As part of a neurodynamic mobilization technique in the ULNPT 1 position (carpal tunnel syndrome).
Ra d ioc a rp a l e xte ns ion (Fig. 6.27) • Direction: Extension localized to the radiocarpal joint. • Symbol: E. • Patient starting position: Supine, lying in the middle of the couch with the forearm partially pronated. • Therapist starting position: Standing by the patient’s right hip facing the right shoulder.
Uses
Localization of forces (position of therapist’s hands)
• As examination of wrist extension with the
• Both the therapist’s hands hold the patient’s
addition of overpressure (up to III+) if necessary. • As a general mobilization of wrist and hand extension. • Recovery of extension after fracture immobilization or injury.
pronated and extended arm at the wrist. • Both thumbs point proximally on the posterior surface of the proximal row of the carpal bones. • The ngers are placed across the front of the carpus.
Fig ure 6.26 • Wrist extension (general).
Fig ure 6.27 • Radiocarpal extension. 347
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• The exed index ngers form the main point of contact against the proximal row of the carpal bones anteriorly. • The index ngers and the thumbs grasp immediately opposite each other, mainly around the scaphoid and lunate but also including the triquetrum. • The thumbs make contact with the base of their terminal phalanges rather than their tips.
Application of forces by therapist (method) • The extension movement is produced through a very rm localized grasp with the ngers and thumbs while lowering the wrist towards the oor as the wrist is extended. • The oscillation is completed by returning the patient’s arm to the starting position while at the same time returning the extended radiocarpal joint to its mid-position.
Variations in the application of forces • The point of contact of the thumbs can be altered to in uence movement more at the scaphoid, lunate or triquetrum. • The extension can be repeated in varying positions of radial and ulnar deviation.
Uses • As a localized mobilization of the radiocarpal joint. • To mobilize the radiocarpal joint after fracture of the wrist or injury. • Combined with horizontal extension to assist in the rehabilitation of patients with carpal tunnel syndrome. • As part of the process of differentiating wrist pain coming from the radiocarpal or midcarpal joints.
Mid c a rp a l e xte ns ion (Fig. 6.28) • Direction: Extension localized to the midcarpal joint, i.e. between the proximal and distal rows of the carpal bones. • Symbol: Midcarpal E. • Patient starting position: Supine, lying in the middle of the couch with the arm and wrist pronated. 348
Fig ure 6.28 • Midcarpal extension.
• Therapist starting position: Standing by the patient’s right side facing the right shoulder.
Localization of forces (position of therapist’s hands) • The proximal end of the distal phalanx of each thumb is placed immediately over the distal margin of the proximal row of the carpal bones posteriorly. • The reinforcing index ngers lie rmly against the anterior surface of the distal row of the carpal bones.
Summary • Thumbs against the proximal row posteriorly. • Index ngers against the distal row anteriorly.
Application of forces by therapist (method) • A tilting action is produced through the index ngers against the distal row of the carpal bones, with the bases of the thumbs preventing movement of the proximal row.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
• There should be no extension of the radiocarpal or the carpometacarpal joints.
Uses • Localization of extension to the midcarpal joint. • Differentiation of pain originating from the radiocarpal or midcarpal joints.
Wris t ulna r d e via tion (ge ne ra l a nd loc a lize d ) (Figs 6.29 and 6.30) • Direction: Ulnar deviation of the wrist and hand. • Symbol: Ulnar deviation – general and localized. • Patient starting position: Supine in the middle of the couch with the elbow exed to 90° and the forearm in its mid-pronation or midsupination position. • Therapist starting position: Standing by the patient’s right side facing the patient’s feet.
Localization of forces (position of therapist’s hands) • The right hand grasps the patient’s forearm distally.
Fig ure 6.29 • Wrist ulnar deviation (general).
• The index nger of the right hand stabilizes around the styloid process of the ulna. • The left hand grasps the anterior and posterior surface of the metacarpals. • The ngers of the right hand reach around the ulnar border of the patient’s hand. • The thumb of the left hand holds through the patient’s rst interosseous space.
Application of forces by therapist (method) • The oscillatory movement performed in any part of the range is produced by a supination action of the therapist’s right forearm, and a pronation action returning the wrist and hand to its starting position.
Variations in the application of forces (for the purpose of differentiating the source of wrist pain) Loca liza tion to the r a dioca r pa l joint • The tips of the thumb and index nger of the left hand stabilize the distal ends of the ulna and the radius medially and laterally in a pinch grip.
Fig ure 6.30 • Wrist ulnar deviation (local). 349
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• The tips of the thumb and index nger of the right hand hold the proximal row of the carpal bones from medially and laterally in a pinch grip. • As the thumb and index nger of the left hand stabilize the ulna and radius, the thumb and index nger of the right hand can tilt the proximal row of the carpal bones into ulnar deviation.
Loca liza tion to the mid ca r pa l a nd ca r pometa ca r pa l joints • The same methods of localization of forces and application of forces are adopted. H owever, for the midcarpal joint the proximal row of the carpal bones is stabilized and the distal row is tilted. For the carpometacarpal joint the distal row is stabilized and the metacarpals are tilted into ulnar deviation.
Uses
• Pain and stiffness with ulnar deviation (mainly clinical groups 2, 3a and 3b).
Wris t ra d ia l d e via tion (ge ne ra l a nd loc a lize d ) (Figs 6.31 and 6.32) • Direction: Radial deviation of the wrist and hand. • Symbol: Radial deviation – general and localized.
Localization of forces (position of therapist’s hands) • This is the same as for ulnar deviation with the exception that the therapist’s left thumb holds the radial styloid and the right hand grasps the metacarpals.
Application of forces by therapist (method) • This is the same as for ulnar deviation with the exception that the movement produced by the therapist’s forearm is radial deviation.
• G eneral ulnar deviation of the wrist and
Variations in the application of forces
hand or localization to the appropriate joint.
• The method of localization of forces and
Fig ure 6.31 • Wrist radial deviation (general). 350
application of forces to the radiocarpal,
Fig ure 6.32 • Wrist radial deviation (local).
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
midcarpal and carpometacarpal joints alone is the same as that described for ulnar deviation with the exception that the joints in question are moved in the direction of radial deviation.
Uses • These are the same as those described for ulnar deviation.
Ra d ioc a rp a l p os te roa nte rior move me nt (Fig. 6.33) • Direction: Movement of the proximal row of the carpal bones on the radius and brocartilaginous disc in the posteroanterior direction. • Symbol: • Patient starting position: Supine in the middle of the couch, elbow exed to 90° and the
forearm in its mid-pronation or mid-supination position. • Therapist starting position: Standing by the patient’s right hip facing the patient’s head.
Localization of forces (position of therapist’s hands) • The left hand holds the posterior surface of the • • • • • • • • •
patient’s hand. The right hand holds the anterior surface of the distal forearm. The right hand is fully supinated and extended at the wrist. The ngers of the right hand point proximally. The heel of the right hand is placed level with the distal end of the radius and ulna. The ngers of the right hand grasp around the patient’s forearm. The heel of the left hand should lie over the carpus. The ngers of the left hand grasp round the patient’s thumb. The thumb of the left hand grasps around the ulnar border of the patient’s hand. The therapist should draw the patient’s wrist and hand towards their body and crouch, directing both forearms opposite to each other.
Application of forces by therapist (method) • The oscillation starts from the neutral position of the wrist and hand and is taken to the limit or appropriate point in the range by an equal and opposite movement of the therapist’s forearms. • The patient’s hand should be kept straight to prevent exion and extension of the wrist.
Variations in the application of forces • The movement can also be performed by using the couch and the left hand to stabilize the radius and ulna while the right hand grasps the back of the patient’s carpus and directs the posteroanterior movement through the heel of the therapist’s hand towards the oor.
Uses • As a grade I or II movement for very painful Fig ure 6.33 • Radiocarpal posteroanterior movement.
wrists. 351
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• As a grade III or IV movement for a predominantly stiff joint. • As a screening test in physical examination with the addition of suf cient overpressure (usually III+).
Ra d ioc a rp a l a nte rop os te rior move me nt (Fig. 6.34) • Direction: Anterior movement of the carpus in relation to the radius and brocartilaginous disc. • Symbol: • Patient starting position: Supine in the middle of the couch with the elbow exed and forearm in the mid-pronation or mid-supination position. • Therapist starting position: Standing between the patient’s right side and the elbow and facing away from the patient.
Localization of forces (position of therapist’s hands) • The right hand grasps the patient’s palm from • • • • • • •
in front. The thumb of the right hand holds around the ulnar border of the patient’s hand. The ngers hold around the radial border. The patient’s thumb lies between the therapist’s ring and middle ngers. The heel of the right hand forms the main point of contact against the carpus anteriorly. The base of the left thumb is placed opposite the distal border of the radius posteriorly. The ngers of the left hand grasp around the radius. The therapist should draw the patient’s wrist and hand towards their body and crouch, directing both forearms opposite each other.
Application of forces by therapist (method) • The oscillation starts from the neutral position of the wrist and hand and is taken to the limit or appropriate point in the range by an equal and opposite movement of the therapist’s forearms.
Variations in the application of forces • The movement can also be performed by using the couch and the left hand to stabilize the radius and ulna while the right hand grasps the front of the patient’s right hand and directs the anteroposterior movement through the heel of the therapist’s hand towards the oor.
Uses • As a grade I or II movement for very painful wrists. • As a grade III or IV movement for a predominantly stiff joint. • As a screening test in physical examination with the addition of suf cient overpressure (usually III+).
Ra d ioc a rp a l s up ina tion (la te ra l rota tion) (Fig. 6.35) • Direction: Supination or lateral rotation of the Fig ure 6.34 • Radiocarpal anteroposterior movement. 352
carpus in relation to the radius and ulna. • Symbols: Sup/
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
• The index nger of the right hand lies across the proximal row of the carpal bones, making rm contact with the triquetrum.
Application of forces by therapist (method) • Further supination of the inferior radioulnar joint is prevented by the therapist’s left hand. • Supination or lateral rotation of the radiocarpal joint is produced by the therapist’s right arm acting through the right wrist and hand. • The tip of the therapist’s right thumb and the distal end of the proximal phalanx of the index nger are the parts through which all of the pressure is transmitted to the carpus, while the therapist’s left thumb and index nger provide counterpressure.
Variations in the application of forces • The supination or lateral rotation movement can be performed in this manner in any position of forearm supination or pronation.
Uses • To increase the range of radiocarpal supination (e.g. after a Colles’ or scaphoid fracture).
Fig ure 6.35 • Radiocarpal supination (lateral rotation).
• Patient starting position: Supine, lying in the middle of the couch with the elbow exed and the forearm in its mid-pronation or mid-supination position. • Therapist starting position: Standing by the patient’s exed right forearm.
Localization of forces (position of therapist’s hands) • The left hand holds the patient’s forearm • • • •
adjacent to the wrist. The left thumb hooks around the lateral border of the distal end of the radius, reaching to the posterior surface of the radius. The index nger of the left hand makes rm contact against the anterior surface of the distal end of the ulna. The right hand holds across the posterior surface of the proximal row of the carpal bones. The thumb of the right hand hooks around the scaphoid to hold it rmly anteriorly.
Ra d ioc a rp a l p rona tion (me d ia l rota tion) (Fig. 6.36) • Direction: Pronation or medial rotation of the carpus in relation to the radius and ulna. • Symbol: Pron/ • Patient starting position: Supine, lying in the middle of the couch with the elbow exed to 90° and the forearm in its mid-pronation or mid-supination position. • Therapist starting position: Standing by the patient’s right hip facing the patient’s shoulder.
Localization of forces (position of therapist’s hands) • The left hand holds the distal end of the • • • •
patient’s forearm. The left thumb hooks posteriorly around the ulna. The base of the left index nger is placed against the anterior surface of the radius. The right hand grasps around the carpus. The right thumb hooks around the triquetrum anteriorly. 353
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• Symbol: • Patient starting position: Supine, lying on the couch with the right arm abducted so that the wrist lies at the edge of the couch, with the patient’s hand beyond it and the thumb pointing towards the oor. • Therapist starting position: Standing beyond the patient’s right wrist facing the patient’s feet.
Localization of forces (position of therapist’s hands) • The left hand holds rmly around the distal end • • • • Fig ure 6.36 • Radiocarpal pronation (medial rotation).
of the patient’s radius and ulna immediately around the styloid processes. The knuckles of the left hand, between the patient’s distal forearm and the surface of the couch, stabilize the patient’s wrist. It may also be necessary for the therapist’s forearm to rest across the patient’s forearm or elbow to stabilize the patient’s arm. The right hand grasps around the posterior surface of the patient’s hand. The right thumb and index nger grasp the carpus around the triquetrum and the pisiform adjacent to the ulnar styloid process.
Application of forces by therapist (method) • The index nger of the right hand presses rmly against the posterior surface of the scaphoid.
Application of forces by therapist (method) • The movement is produced by the pressure of the therapist’s left hand against the patient’s carpus while the therapist’s right hand stabilizes the patient’s forearm by applying an equal and opposite counterpressure.
Variations in the application of forces • The pronation or medial rotation movement of the radiocarpal joint can be performed in any position of forearm pronation or supination.
Uses • To increase the range of radiocarpal pronation or medial rotation.
Ra d ioc a rp a l la te ra l tra ns ve rs e move me nt • Direction: Transverse lateral movement of the carpus in relation to the radius and ulna. 354
• The movement of the patient’s hand towards the oor is produced through the therapist’s left arm and shoulder. • The therapist’s left hand should move as a single unit with the patient’s hand.
Variations in the application of forces The lateral transverse movement can be performed: 1. with the hand in any position of radial or ulnar deviation, 2. with inclinations anteriorly or posteriorly, 3. with the wrist in any position of pronation and supination or 4. with the radiocarpal joint surfaces compressed together or distracted. The choice depends on the variation which best reproduces the patient’s symptoms or achieves the desired effects.
Uses • The movement is most effective as an oscillatory grade IV to IV+ or as a large amplitude grade III.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Ra d ioc a rp a l me d ia l tra ns ve rs e move me nt • Direction: Transverse movement medially of the carpus in relation to the radius and ulna. • Symbol: • Patient starting position: Supine, lying in the middle of the couch with the right arm abducted, the patient’s wrist lying at the edge of the couch with the hand beyond it and the thumb pointing towards the ceiling.
Localization of forces (position of therapist’s hands) • The left hand holds rmly around the distal end • • • •
of the patient’s radius and ulna immediately around the styloid processes. The knuckles of the left hand, between the patient’s distal forearm and the surface of the couch, stabilize the patient’s wrist. It may also be necessary for the therapist’s forearm to rest across the patient’s forearm or elbow to stabilize the patient’s arm. The right hand grasps around the posterior surface of the patient’s hand. The right thumb and index nger grasp the carpus around the triquetrum and the pisiform adjacent to the ulnar styloid process.
Application of forces by therapist (method) • The movement of the patient’s hand towards the oor is produced through the therapist’s left arm and shoulder. • The therapist’s left hand should move as a single unit with the patient’s hand.
Uses The movement is most effective as an oscillatory grade IV to IV+ or as a large amplitude grade III.
Inte rc a rp a l horizonta l e xte ns ion (Fig. 6.37) • Direction: Extension of the carpal bones in a horizontal plane. • Symbol: Intercarpal H E. • Patient starting position: Supine, lying in the middle of the couch with the elbow exed to 90° and the forearm supinated. • Therapist starting position: Standing by the patient’s right side beyond the exed and supinated forearm, facing the patient’s head.
Localization of forces (position of therapist’s hands) • The tips of the pads of both thumbs, placed against the centre of the carpus posteriorly, hold the patient’s hand from the back. • The index and middle ngers hold around the pisiform medially and the carpometacarpal joint of the thumb laterally.
Application of forces by therapist (method) • The oscillatory movement is produced by thumb pressure against the centre of the carpus posteriorly and pulling against the medial and lateral margins of the carpus with the ngers.
Variations in the application of forces The lateral transverse movement can be performed:
• With the hand in any position of radial or ulnar deviation • With inclinations anteriorly or posteriorly • With the wrist in any position of pronation and supination or • With the radiocarpal joint surfaces compressed together or distracted. The choice depends on the variation which best reproduces the patient’s symptoms or achieves the desired effects.
Fig ure 6.37 • Intercarpal horizontal extension. 355
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• The action is produced by extension of the therapist’s wrists and facilitated by pushing the patient’s hand away with the thumbs.
Variations in the application of forces • The movement can be localized to the proximal or distal row of the carpal bones using the tips of the thumbs. • The movement can also be localized to each carpal bone as well as inclining thumb pressure medially, laterally, cephalad, caudad or diagonally).
Uses • The mobilization of individual carpal bones into horizontal extension. • Stretching the anterior carpal structures. • As an interface technique for median nerve entrapment in the carpal tunnel.
Inte rc a rp a l horizonta l e xion (Fig. 6.38) • Direction: Flexion of the carpal bones in a horizontal plane. • Symbol: Intercarpal H F. • Patient starting position: Supine, lying in the middle of the couch with the elbow exed to 90° and the forearm supinated. • Therapist starting position: Standing by the patient’s right elbow facing across the patient’s body.
Fig ure 6.38 • Intercarpal horizontal exion.
• The right hand produces a cupping action of the patient’s hand around the pivot formed by the therapist’s left thumb.
Variations in the application of forces Localization of forces (position of therapist’s hands) • The right hand grasps the back of the patient’s hand with the ngers pointing distally. • The right hand contacts the medial and lateral margins of the carpus. • The left thumb tip is placed against the palmar surface of the carpus to apply an anteroposterior pressure to the carpus. • The forearms are directed opposite each other.
Application of forces by therapist (method) • The oscillation is produced by opposite pressure through the forearms. 356
• The left thumb tip and right hand can localize pressure to the carpus as a whole, or to the proximal or distal rows of the carpal bones. • The left thumb can localize its pressure to the individual carpal bones anteriorly as well as apply pressure inclined medially, laterally, cephalad, caudad or diagonally.
Uses • Local carpal pain and stiffness (rows or individual bones) • Recovery of horizontal exion after fracture or immobilization. • Intercarpal stiffness as in Sudeck’s atrophy. • As an interface mobilization of the carpal tunnel for median nerve entrapment.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
P os te roa nte rior a nd a nte rop os te rior inte rc a rp a l move me nts (Figs 6.39 and 6.40) • Direction: Movement of the individual carpal bones in a posteroanterior or an anteroposterior direction in relation the adjacent carpal bone, radius, ulna or adjacent metacarpal. • Symbols: Intercarpal , • Patient starting position: Supine, lying in the middle of the couch with the forearm resting on the couch and pronated (posteroanterior) or supinated (anteroposterior). • Therapist starting position: Standing by the patient’s right side beyond the hand, facing the patient’s head.
Localization of forces (position of therapist’s hands) Poster oa nter ior • The maximum breadth of the thumb tips are placed adjacent to each other on the appropriate carpal bone or intercarpal joint. • The ngers spread over the adjacent area of the hand for stability. • The arms and thumbs are positioned in a posteroanterior direction.
Anter oposter ior • The thumbs make contact with the palmar surface of the patient’s supinated hand against the appropriate carpal bone or intercarpal joint.
Fig ure 6.39 • Intercarpal movement posteroanterior.
• The ngers spread over adjacent areas of the hand for stability. • The thumbs and arms are positioned in an anteroposterior direction.
Application of forces by therapist (method) • The posteroanterior or anteroposterior movement is produced by pressure from the therapist’s arms being transmitted through the spring-like action of the thumbs against the appropriate carpal bone or intercarpal joint.
Variations in the application of forces • The posteroanterior or anteroposterior movement can be included medially, laterally, cephalad, caudad or diagonally. • A combination of posteroanterior movement of one carpal bone and anteroposterior movement of the adjacent carpal bone can be produced simultaneously by the therapist gripping the individual bones in a pincer grip with the thumbs and index ngers. The opposite movements can then be performed. • The posteroanterior movement of the individual carpal bones can be emphasized by the therapist’s thumbs posteriorly during the horizontal extension movement. • The anteroposterior movement can be emphasized by the therapist’s left thumb
Fig ure 6.40 • Intercarpal movement anteroposterior. 357
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against the anterior surface of the carpal bones during the movement of horizontal exion.
Uses • Very painful intercarpal movement. • Prevention of stiffness in Sudeck’s atrophy. • Mobilization of the intercarpal joints after injury or immobilization.
Wris t a nd ha nd inte rc a rp a l longitud ina l move me nt c a ud a d a nd c e p ha la d (Figs 6.41 and 6.42)
• Patient starting position: Supine, lying in the middle of the couch with the elbow exed to 90°, the wrist in its neutral position and the forearm in its mid-pronation or mid-supination position. • Therapist starting position: Standing by the patient’s right side facing the right shoulder.
Localization of forces (position of therapist’s hands) • The left hand holds around the lower end of
cephalad (compression) movement of the carpus and hand in relation to the radius and ulna. • Symbol:
the patient’s humerus from posteriorly. • The thumb of the left hand is placed laterally for longitudinal cephalad movement and over the patient’s biceps for longitudinal caudad movement. • The ngers of the left hand spread around the lower end of the humerus laterally.
Fig ure 6.41 • Wrist and hand longitudinal movement cephalad.
Fig ure 6.42 • Wrist and hand longitudinal movement caudad.
• Direction: Longitudinal caudad (distraction) and
358
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
• The right hand adopts the ‘shake hands’ grip with the thumb and ngers grasping round the patient’s metacarpals. • The index nger of the right hand extends down the patient’s forearm to maintain the neutral wrist position.
Application of forces by therapist (method) • With the grasp round the metacarpals, stability of the upper arm and the patient’s wrist in its neutral position, the longitudinal cephalad (compression) movement is produced by directing pressure through the therapist’s hand and through the carpus along the line of the radius and ulna. • The longitudinal movement caudad (distraction) is produced by a pulling action through the patient’s metacarpals in line with the radius and ulna.
Variations in the application of forces • The longitudinal movements can be performed with the wrist in exion, extension, deviation or rotation. • The longitudinal movements can be performed in combination with AP and PA of the individual carpal bones. • An attempt can be made to bias the movement in line with individual carpal pillars and metacarpals (e.g. biased towards the lunate, capitate and third metacarpal).
A
B
Uses • Very painful wrist and hand movements. • In combination with other movements.
P is iform move me nts (Fig. 6.43) • Direction: Movements of the pisiform in a variety of directions in relation to the triquetrum. • Symbols: , , , • Patient starting position: Supine, lying in the middle of the couch with the forearm supinated and the back of the hand resting against the couch or the therapist’s body. • Therapist starting position: Standing by the patient’s right hip facing across the patient’s body.
Localization of forces (position of therapist’s hands) • The therapist’s body and one hand maintain stability of the patient’s hand and forearm while the thumb pad of the other hand directs pressure against the different surfaces of the pisiform bone.
Application of forces by therapist (method) • The oscillation is produced by the therapist’s thumb, usually as a grade III or IV.
C
Fig ure 6.43 • Pisiform movements. 359
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A
B
Fig ure 6.44 • Carpometacarpal extension.
Variations in the application of forces • Any direction of movement around the ‘clock face’ of the pisiform bone is possible depending on the limited or painful directions. • Movements can be performed with the thumb also applying a compression force to the pisiform during its movements. • By grasping the pisiform between the thumb and index nger laterally it can be lifted away from the triquetrum and therefore moved with the addition of a distraction force.
• Symbols: Carpometacarpal E, F. • Patient starting position: Supine, lying in the middle of the couch with the forearm held close to the therapist’s body and in pronation or extension and supination or f exion.
Uses • A stiff painful pisiform. • As an interface technique for ulnar nerve entrapment adjacent to the pisiform or in the wrist. • After injury or laceration of the exor carpi ulnaris to restore normal stretch capacities.
Ca rp ome ta c a rp a l e xte ns ion a nd (Figs 6.44 and 6.45)
e xion
• Direction: Movement of the metacarpals in an extension and exion direction in relation to their corresponding carpal bones. The same technique can be used to move the metacarpals in the anteroposterior and posteroanterior, transverse medial and lateral, medial and lateral rotation, and the longitudinal caudad (distraction) and longitudinal cephalad (compression) directions. 360
Fig ure 6.45 • Carpometacarpal exion.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
• Therapist starting position: or extension – standing by the patient’s slightly exed right forearm facing across the patient’s body; or f exion – standing by the patient’s upper arm facing the patient’s feet.
Localization of forces (position of therapist’s hands) For extension (la ter a l CMC joints) • The hands hold the patient’s partly pronated • • • •
hand from its lateral side. The left hand grasps the relevant carpal bone. The right hand grasps the relevant and adjacent metacarpal. The right hand grasps through the rst interosseous space. The tip of the right thumb is placed against the base of the metacarpal posteriorly.
Application of forces by therapist (method) For extension • The use of grades III and IV is most common. • The movement is produced by the therapist moving the patient’s hand away and applying pressure through the thumbs with counterpressure with the ngers to assist the extension.
For exion • The therapist produces the movement by pushing the patient’s hand away and at the same time the therapist’s glenohumeral joints are adducted and the elbows extended to transmit pressure through the thumbs to the palm. • The movement can be produced either with both thumbs or by stabilizing the carpus with the left hand and exing the metacarpal with the right.
For extension (CMC of the little nger ) • Use the same grip as above except the pad
Variations in the application of forces
of the thumb is placed over the hamate bone. • The right hand holds the ulnar border of the patient’s right hand in order to grasp the fth metacarpal. • The exed index nger supports the fth metacarpal distally and anteriorly. • The thumb of the right hand makes contact with the base posteriorly.
movements of the CMC joint such as anteroposterior and posteroanterior accessory movements and compression and distraction. • A transverse accessory movement can be produced by adjusting the thumb and nger localizations so that movement is produced in the transverse lateral and medial directions. • Rotation at the joint can be produced by xing the appropriate carpal bone with one hand and holding onto the appropriate proximal phalanx held in 90° of exion in the other hand. The appropriate MCP joint is then moved medially and laterally resulting in medial and lateral rotation of the CMC joint. • Combinations of movements are also possible including, for example, exion and extension combined with anteroposterior or posteroanterior movements or rotation with compression ordistraction.
For exion • Both hands hold the patient’s supinated hand. • The left hand holds the medial border of the patient’s wrist. • The tip of the left thumb is placed in the palm of the patient’s hand over the appropriate carpal bone.
For exion (for the second CMC joint) • The right hand holds the second metacarpal through the patient’s rst interosseous space. • The tip of the right thumb is placed against the base of the metacarpal anteriorly. • The exed index nger of the right hand holds against the distal end of the metacarpal posteriorly.
• The same grip can be used to perform other
Uses • Mainly grade III and IV movements for stiff orpainful or stiff CMC joints.
Inte rme ta c a rp a l move me nts (Fig. 6.46) • Direction: The main movements possible between the metacarpals are general and 361
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compression (transverse) – standing beyond the patient’s exed and supinated forearm facing the back of the hand.
Localization of forces (position of therapist’s hands) G ener a l hor izonta l exion (the whole r ow of meta ca r pa ls) • The pad of the left thumb is placed in the palm • • • A
•
of the patient’s hand over the distal end of the third metacarpal. The right hand cups across the dorsum of all the metacarpals distally. The right thumb presses against the posterior surface of the second metacarpal. The ngers of the right hand (particularly the index nger) press against the posterior surface of the fth metacarpal. If the left thumb is placed against the fourth metacarpal this will change the peak of the movement.
Loca lized hor izonta l exion • Both hands grasp the patient’s hand. • The right thumb holds the patient’s fth metacarpal posteriorly. • The tips of the right index and middle ngers hold the fth metacarpal anteriorly. • The left hand holds the adjacent fourth metacarpal between the pads of the index and middle ngers anteriorly and the pad of the thumb posteriorly.
G ener a l hor izonta l extension • Both hands hold the patient’s hand. • The pads of the thumbs are placed against the B
Fig ure 6.46 • Intermetacarpal movements: A HF; B HE.
localized horizontal exion, general and localized horizontal extension, anteroposterior and posteroanterior movements, and compression (in a transverse direction). • Symbols : H F, H E , , • Patient starting position: Supine lying with the elbow exed to 90° and the forearm supinated and held close to the therapist’s body. • Therapist starting position: or H F, AP, PA – standing facing the back of the patient’s exed and supinated forearm; or H E, 362
distal end of the posterior surface of the third metacarpal. • The ngers hold round the medial and lateral margins of the patient’s hand to reach to the anterior surface of the second and fth metacarpals distally.
Loca lized hor izonta l extension • The same localization of forces described for localized horizontal exion apply.
Poster oa nter ior or a nter oposter ior • The same localization of forces described for localized horizontal exion apply.
Compression (tr a nsver se) • The ‘shake hands’ grip is adopted (i.e. right hand to right hand).
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
• O ne hand grips around the heads of the metacarpals with one hand. • The other hand stabilizes the heads of the metacarpals in a straight line from the radial to the ulnar sides.
Application of forces by therapist (method) G ener a l hor izonta l exion • Small or large amplitude movements are produced by the therapist’s hands moving in opposite directions.
Loca lized hor izonta l exion • While the therapist’s left hand stabilizes the fourth metacarpal, the therapist’s right hand moves the fth metacarpal in a circular direction. • When the second metacarpal is to be mobilized on the third, the therapist’s left hand performs the movement, whereas when the fourth and fth metacarpals are to be mobilized the therapist’s left hand holds the fourth metacarpal while the right hand moves the fth metacarpal around the fourth. • If the third metacarpal is to be mobilized on the fourth the therapist’s left hand performs the movement and the right hand acts as the stabilizing force. • When the fourth metacarpal is to be mobilized on the third, the reverse is the case.
posteroanteriorly in relation to the stabilized neighbouring metacarpal).
Compression (tr a nsver se) • The movement is produced by the therapist alternately squeezing and relaxing the gaps around the patient’s metacarpal heads.
Uses • Movements do not usually become disturbed unless caused by trauma.
Me ta c a rp op ha la nge a l a nd inte rp ha la nge a l joint e xion a nd e xte ns ion (d e s c rib e d for MCP joints ) (Figs 6.47 and 6.48) • Direction: Flexion and extension of the proximal phalanx in relation to the metacarpal, or of the interphalangeal, joints. • Symbols: MCP, IP F, E. • Patient starting position: Supine, lying with the elbow exed and forearm supinated. • Therapist starting position: Standing by the patient’s side facing across the body at the level of the patient’s exed elbow.
Localization of forces (position of therapist’s hands) (for the index nger) • The right hand holds the proximal phalanx of the patient’s index nger between the thumb
G ener a l hor izonta l extension • The extension movement is performed by a pulling action with the ngers of both hands pivoting the patient’s metacarpals around the thumbs on the third metacarpal while at the same time pushing the patient’s hand away (as a grade III large amplitude).
Loca lized hor izonta l extension • The same application of forces described for localized horizontal exion apply except that the movement is one of pivoting towards extension around stabilized adjacent metacarpals.
Poster oa nter ior or a nter oposter ior movements • The same application of forces described for localized horizontal exion apply except that the metacarpals are moved so as to traverse parallel lines in opposite directions (i.e. one metacarpal is moved anteroposteriorly or
Fig ure 6.47 • Metacarpophalangeal and interphalangeal joint: exion. 363
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Me ta c a rp op ha la nge a l a nd inte rp ha la nge a l joint a b d uc tion a nd a d d uc tion (d e s c rib e d for MCP joint) (Figs 6.49 and 6.50) • Direction: Abduction and adduction of the proximal phalanx in relation to the adjacent metacarpal or at the interphalangeal joint. • Symbols: MCP, IP Ab, Ad.
Fig ure 6.48 • Metacarpophalangeal and interphalangeal joint: extension.
and the index nger, both of which are directed proximally. • The left hand stabilizes the patient’s hand, particularly around the second metacarpal between the thumb and index nger.
Application of forces by therapist (method) Flexion • The joint is exed comfortably, at the limit of
Fig ure 6.49 • Metacarpophalangeal and interphalangeal joint: abduction.
the range if necessary (e.g. a small amplitude grade IV is performed by the therapist’s right hand while the metacarpals are stabilized with the left hand).
Extension • Extension is produced by the combined action of extending the proximal phalanx on the metacarpal and the metacarpal on the phalanx. • Alternatively, the movement can be produced by stabilizing the metacarpal and moving the proximal phalanx into extension. • Small or large amplitudes can be used.
Va r ia tions in the a pplica tion of for ces • The exion and extension can be combined with anteroposterior or posteroanterior movements at their limit, or with compression or distraction.
Uses • Stiff ngers. 364
Fig ure 6.50 • Metacarpophalangeal and interphalangeal joint: adduction.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
• Patient starting position: Supine, lying in the
• The oscillatory movement is produced by the
middle of the couch with the elbow exed and pronated for adduction and supinated for abduction. • Therapist starting position: Standing by the patient’s side at the level of the elbow facing across the patient’s body.
Variations in the application of forces
Localization of forces (position of therapist’s hands) (for the index nger)
• Compression or distraction • A transverse glide • Inclinations anteriorly or posteriorly.
Abduction • The left hand holds the posterior surface of the
Uses
• • • • •
patient’s right hand. The right hand holds the patient’s index nger. The left hand holds the posterior surface of the patient’s hand from the radial side. The left thumb, pointing distally, is placed against the lateral surface of the second metacarpal distally. The ngers of the left hand grasp the ulnar border of the patient’s hand. The pad of the right thumb, pointing proximally, stretches along the lateral surface of the proximal phalanx to its base.
Add uction • The left hand holds the posterior surface of the • •
• •
patient’s hand around its radial border. The left thumb wedges into the second interosseous space as much as possible. The ngers of the left hand reach around the patient’s thumb and through the rst interosseous space to stabilize the patient’s hand. The right hand grasps the patient’s index nger. The pad of the right thumb, pointing proximally, holds against the medial surface of the proximal phalanx.
therapist’s arms acting through both hands while pushing the patient’s hand away.
The abduction or adduction movements can be combined with:
• Stiff ngers. • Restoration of movement after collateral ligament injury.
Me ta c a rp op ha la nge a l a nd inte rp ha la nge a l joint me d ia l a nd la te ra l rota tion (d e s c rib e d for MCP joints ) (Figs 6.51 and 6.52) • Direction: Medial rotation or lateral rotation of the phalanges in relation to stabilized metacarpals or at interphalangeal joints. • Symbols: MCP, IP , • Patient starting position: Supine, lying in the middle of the couch with the elbow exed and the forearm in its mid-pronation or midsupination position.
Application of forces by therapist (method) Abduction • The oscillatory movement is produced by movement of the therapist’s two hands combining abduction with pushing the patient’s hand away. • Small or large amplitude movements can be performed in any part of the range. • Adduction
Fig ure 6.51 • Metacarpophalangeal and interphalangeal joint: medial rotation. 365
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• The index nger passes through the rst • • • •
interosseous space to reach the palm of the patient’s hand. The remaining ngers grasp around the thenar eminence. The right hand holds the patient’s exed nger. The right thumb is placed against the lateral surface of the proximal IP joint. The index nger of the right hand is placed against the medial surface of the distal IP joint.
Application of forces by therapist (method) Med ia l r ota tion • The movement is produced entirely by the
Fig ure 6.52 • Metacarpophalangeal and interphalangeal joint: lateral rotation.
therapist’s right hand while the left hand stabilizes the patient’s hand. • The therapist pivots the distal phalanx around the therapist’s thumb tip causing the patient’s proximal phalanx to medially rotate.
• Therapist starting position: Standing by the
La ter a l r ota tion • The therapist produces the rotation by
patient’s side, level with the exed elbow and facing across the patient’s body.
Localization of forces (position of therapist’s hands) (for the index nger) Med ia l r ota tion • The left hand stabilizes the second metacarpal by holding it rmly between the ngers anteriorly and the thumb posteriorly. • The right hand holds the slightly exed index nger in 10° of MCP exion and 80° of proximal IP exion. (The maximum range of medial rotation is obtained when the MCP is positioned in a few degrees of exion as this is the joint’s mid exion/ extension position. H owever, the degree of exion or extension used in treatment will be determined by the presenting pain and stiffness.) • The tip of the right thumb is placed against the medial aspect of the proximal IP joint. • The tips of the right index and middle ngers are placed against the lateral surface of the patient’s middle and distal phalanges.
La ter a l r ota tion • The left hand holds across the posterior surface of the patient’s hand. • The ngers of the left hand are threaded around the lateral border of the hand. 366
movement of the left hand and forearm while the therapist’s right hand stabilizes the patient’s hand.
Variations in the application of forces • The rotation can be performed with compression or distraction or in any position of exion, extension, abduction or adduction.
Uses • Stiff ngers. • With compression in minor symptoms produced by osteoarthritis.
Me ta c a rp op ha la nge a l a nd inte rp ha la nge a l joint longitud ina l move me nt c a ud a d (d is tra c tion) a nd c e p ha la d (c omp re s s ion) – d e s c rib e d for the MCP joint (Figs 6.53 and 6.54) • Direction: Longitudinal movement caudad (distraction) and cephalad (compression) of the proximal phalanx in relation to the adjacent metacarpal or at the IP joint. • Symbols: MCP, IP , • Patient starting position: Supine, lying in the middle of the couch with the elbow exed to 90° and the forearm in its mid-pronation or mid-supination position.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
• The right hand holds the patient’s index nger. • The left hand holds the second metacarpal • • •
•
Fig ure 6.53 • Metacarpophalangeal and interphalangeal joint: longitudinal movement caudad (distraction).
• Therapist starting position: Standing by the patient’s right side, level with the forearm and hand, facing across the patient’s body.
Localization of forces (position of therapist’s hands) (for the index nger) Longitudina l ca ud a d • The left hand grasps rmly around the lateral border of the patient’s right hand.
• •
between the exed index nger and thumb. The proximal IP joint of the left index nger holds the anterior surface of the distal end of the metacarpal. The left thumb holds rmly against the shaft of the metacarpal posteriorly. The right hand grasps the patient’s index nger in a similar fashion, i.e. the fully exed index nger holds the patient’s proximal phalanx anteriorly and the thumb grasps along the shaft of the same phalanx. The patient’s MCP joint is then positioned midway between its other ranges to permit maximum caudad movement. Longitudinal cephalad The same localization of forces as for longitudinal caudad is applied except the ngers and palm hold the whole of the patient’s index nger, which should be slightly exed at each IP joint.
Application of forces by therapist (method) Longitudina l ca ud a d • The movement is produced by the therapist pulling the hands away from each other to produce distraction with the MCP joint slightly exed. • This slight exion is maintained by rm pressure against the anterior surface of the patient’s metacarpal and phalanx, adjacent to the joints, using the therapist’s index nger at the proximal IP joint.
Longitudina l cepha la d • The movement of compression is applied by the squeezing together of the therapist’s hands which hold the metacarpal and phalanx rmly.
Variations in the application of forces • The movements can be performed in isolation or more often combined with exion, extension, abduction, adduction, AP, PA and rotation.
Uses • Stiff ngers. • Very painful joint surface disorders Fig ure 6.54 • Metacarpophalangeal and interphalangeal joint: longitudinal movement cephalad (compression).
(distraction). • Minor joint surface disorders (compression). 367
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Me ta c a rp op ha la nge a l a nd inte rp ha la nge a l joint p os te roa nte rior a nd a nte rop os te rior move me nt (d e s c rib e d for the MCP joint) (Figs 6.55 and 6.56)
• The ngers of the right hand hook around the
• Direction: Posteroanterior and anteroposterior
Application of forces by therapist (method)
movement of the proximal phalanx on the adjacent metacarpal or at the IP joint. • Symbols: MCP, IP , • Patient starting position: Supine, lying in the middle of the couch with the elbow exed to 90° and the forearm in its mid-pronation or mid-supination position. • Therapist starting position: Standing by the patient’s side, level with the forearm, facing across the patient’s body.
anterior surface of the phalanx. • The tip of the right thumb is placed against the head of the proximal phalanx posteriorly.
• Posteroanterior – pressure is applied acting through the tip of the therapist’s right thumb against the posterior surface of the head of the proximal phalanx immediately adjacent to the MCP joint. The exors of the therapist’s thumbs must not produce the movement. • Anteroposterior – pressure is applied against the head of the proximal phalanx anteriorly by the IP joint of the therapist’s exed index nger.
Variations in the application of forces Localization of forces (position of therapist’s hands) (for the index nger) • The left hand holds the patient’s second metacarpal rmly with the fully exed index nger anteriorly and the thumb posteriorly. • The left thumb makes contact with the posterior surface proximal to the joint. • The proximal IP joint of the therapist’s index nger makes contact with the anterior surface proximal to the joint. • The right hand grasps the proximal phalanx of the patient’s index nger.
Fig ure 6.55 • Metacarpophalangeal and interphalangeal joint: posteroanterior movement. 368
• The movement can also be performed with the joint surfaces distracted or rmly compressed against each other. • The movement can be inclined in a variety of directions. • Frequently used in combination with exion, extension, abduction, adduction or rotation.
Uses • Stiff ngers (at the limit of the stiff physiological movement). • Clinical group 1, for very painful joints.
Fig ure 6.56 • Metacarpophalangeal and interphalangeal joint: anteroposterior movement.
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Me ta c a rp op ha la nge a l a nd inte rp ha la nge a l joint ge ne ra l e xion, e xte ns ion a nd c irc umd uc tion • Direction: G eneral exion, extension and circumduction of the MCP and IP joints. • Symbols: MCP, IP F, E, circumduction (general). • Patient starting position: Supine, lying in the middle of the couch with the elbow exed to 90° and the forearm in its mid-pronation or mid-supination position. • Therapist starting position: Standing by the patient’s side, level with the forearm and facing across the patient’s body.
Localization of forces (position of therapist’s hands) • The left hand holds across the back of the patient’s right hand from the medial side. • The ngers grasp the rst interosseous space to reach the palm of the patient’s hand. • The therapist’s thenar eminence and thumb of the right hand hold across the back of the patient’s hand. • The right hand holds the patient’s four ngers from the medial side between the ngers anteriorly and the thenar eminence posteriorly.
Application of forces by therapist (method) With the metacarpals held rmly the following general movements can be performed:
Fig ure 6.57 • First carpometacarpal exion.
different. The movement of opposition is an additional thumb movement which is a combination of exion, abduction and rotation. • Symbols:1st CMC joint F, E, Ad, Ab, opposition, ceph, , , , • Patient starting position: Supine, lying in the middle of the couch with the elbow exed to 90°. • Therapist starting position: Standing by the patient’s side, level with the exed elbow, facing across the patient’s body.
1. MCP joint exion with IP extension 2. MCP extension with IP exion 3. MCP circumduction with a circling action of the right hand.
Uses • As grade II general hand loosening movements. • As easing off of treatment soreness. • For general stiffness and pain in all joints as in osteoarthritis or rheumatoid arthritis. • To loosen off stiffness postimmobilization (e.g. after a Colles’ fracture).
Thumb move me nts ( rs t c a rp ome ta c a rp a l joint) (Figs 6.57-6.59) • Direction: Movements of the thumb are identical with those of the ngers even though the planes of the thumb movements are
Fig ure 6.58 • First carpometacarpal extension. 369
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• The localization of forces is the same as those described for rotation of the index nger.
Poster oa nter ior movement (includ ing a nter oposter ior, a nd tr a nsver se media l a nd la ter a l) • The right hand grasps the patient’s thumb. • The left hand grasps the patient’s wrist at its radial border. • The tips of both thumbs are placed: 1. against the posterior surface of the rst metacarpal, immediately adjacent to the CMC joint; 2. against the trapezium; 3. on the joint line.
Application of forces by therapist (method) • Flexion: the exion movement is produced Fig ure 6.59 • Carpometacarpal posteroanterior movement.
Localization of forces (position of therapist’s hands)
•
•
Flexion • The left hand stabilizes the patient’s wrist with • •
• •
the ngers across the anterior surface and the thumb posteriorly. The left index nger must cross in front of the trapezium to stabilize it during thumb exion while not obstructing metacarpal movement. The right thumb and index nger grasp the patient’s thumb with the therapist’s thumb across the posterior surface of the metacarpal and the index nger across the anterior surface. Extension. The same localization of forces as for exion applies except that the tip of the left thumb is placed against the dorsal surface of the trapezium and the trapezoid.
Adduction, a bduction, opposition • As above, one hand stabilizes the carpus at the trapezium and trapezoid, while the other hand produces the movement of the metacarpal in the desired direction.
Longitudina l cepha la d (compression) • The localization of forces is the same as those described for longitudinal movement cephalad of the index nger. • Rotation. 3 70
•
•
through the therapist’s right hand while the left hand stabilizes the proximal part of the joint. Extension: the extension movement is produced mainly through the therapist’s contact on the anterior surface of the rst metacarpal, pivoting it around the therapist’s right thumb while the left thumb stabilizes the proximal part of the joint. Adduction, abduction, opposition: these movements are performed in the appropriate direction by the therapist’s left thumb and index nger stabilizing the trapezium and trapezoid while the therapist’s right thumb and index nger move the metacarpal. Note that the opposition also includes medial rotation as part of the oscillatory movement. Longitudinal movement cephalad and rotation: the application of forces for these movements is the same as those described for the index nger. Posteroanterior (anteroposterior, transverse medial and lateral): the posteroanterior movement, for example, is produced by the pressure of the thumbs against the base of the metacarpal or the index ngers. The pressure should arise from the therapist’s arms and must not be produced by the thumb exors.
Variations in the application of forces • Any of the above movements can be combined, depending on the directions which are stiff or painful.
Uses • The thumb is often subjected to osteoarthritic changes so movements which include
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Box 6.10 Chronic and minor wrist and hand symptoms • • • • • •
Supine: exion and extens ion Supination and pronation (through metacarpals ) Radial and ulnar deviation AP and PA movement HF and HE Longitudinal caudad and cephalad
compression when the symptoms are minor can be most effective. • Pain and stiffness in the joint after overuse, trauma or following fracture. Box 6.10 summarizes the extent of examination required when chronic minor wrist and hand symptoms are present, Box 6.11 shows the screening tests required to prove the wrist and hand are unaffected, and Box 6.12 shows how to examine a thumb with chronic minor symptoms.
Screening tes ts Normally screening tests are used after the rst treatment. Each new treatment can screen a new structure, which can be better evaluated individually. Structures to be screened:
• Cervical spine: active exion, extension, rotation left, right, inferior cervical quadrant and PAIVM’s.
Box 6.11 Proving the area unaffected • • • •
F and E (f ngers to wris t) Supination and pronation Wris t deviation ( ) ceph, caud
Box 6.12 Chronic and minor base of thumb symptoms Proving that the thumb is , in act, una ected F/E, E with ( , ), Rotn with compres s ion
• Shoulder complex: active exion, abduction, H BB, horizontal exion, and passively medial rotation in 90° abduction, glenohumeral quadrant and locking position. • Elbow: active exion, extension, pronation, supination and passively exion/ adduction, exion/ abduction, extension/ adduction, extension/ abduction, in 90° exion: pronation, supination combined with compression intra-articular. • Thoracic spine: cough, active extension, rotation left and right and PAIVMs. • First rib: cervical extension, lateral exion and passive accessory movements. It includes of course a reassessment after each screening test
Treatment o wris t and hand conditions – an overview For treatment, the differential functional analysis and the creativity of the therapist is much more relevant than the different laws of biomechanics. All the techniques described above must have the exibility to be combined, adapted and modi ed in unrestricted ways. Thus, for the simple treatment of a monoarthritis of the second carpometacarpal joint of a woman in her fties, the important accessory movements found to be impaired are rotation and anteroposterior movements, which, if used in treatment alone, would have been ineffective. For effective treatment, however, to completely clear the symptoms and reduce crepitus, rotation and anteroposterior movements were used, rstly combined with distraction, then with compression through the whole physiological range and then along with variations and all possible angulations (for example, rotation and anteroposterior movements in extension or adduction IV−, with compression IV). In this example the key to successful treatment is graded exposure to movement in combinations and functional corners so as to ensure full pain-free capacity of movement at the carpometacarpal joint is achieved. Sometimes a tiny movement problem with a huge psychosocial component will moderate the effect of manual therapy and limit its effectiveness. A patient, a manual therapist in his forties, lost the motor control and strength of the long exor of his thumb. There was no pain and no other other 3 71
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restriction. H e was unable to work because he was unable to perform accessory movement techniques using his thumb. The whole of his family was referred to a psychiatrist because his doctor thought he was trying to make a fraudulent insurance claim. Medical and manual therapy examination did not show that there was anything wrong with him. A neurologist found that he had a form of Parsonage– Turner syndrome – idiopathic or viral brachial amyotrophic neuralgia. The affected muscle, in this case only the exor pollicis longus, became weak and atrophied, but after one-and-a-half years resolved completely. In this very rare type of case (incidence around 1.5 in 100,000, Beghi et al. 1985), manual therapy has no role to play, but in nearly all other peripheral neuropathies, manual therapy shows ef cacy. O nce again, the potential for the success of manual therapy comes from combining the different possibilities:
• Accessory movements on entrapment sites in neural tension • Nerve sliders in the functional position • Cervical gliders in speci c ULNT • Thoracic mobilization in slump position.
Ma na ge me nt Apart from all the mobilization techniques described above, which correspond to more than 95% of all treatment with passive movement, manipulation (V) can be used when joint mobility remains restricted or blocked. The main manipulation techniques for the hand are:
• traction thrust (V) of MCP (Fig. 6.53 or CMC 1 Fig. 6.44B, radioscaphoid, radiolunate, radiotriquetrum (Fig. 6.42); • PA thrust (V) of MCP (Fig. 6.55), scaphoid, lunate, triquetrum, capitate (Fig. 6.27 or Fig. 6.39 with emphasis of thrust on each carpal bone); • transverse thrust (V) of CMC1 (Fig. 6.58). Manipulation consists of a high-velocity, smallamplitude thrust within the anatomical limit of the joint. It is the velocity and not the force which makes the difference to mobilization. The MCP needs a distraction of around 8.3 kg to produce the cracking noise known as cavitation. (Roston & H aines 1947). Stabilization may be necessary after posttraumatic lesion or because of functional instability. By teaching exercises to the patient, dissociation is learned by reinforcing the deep and short layers (M. lumbricales, interossei) while mobilizing the long and super cial mobilizing muscles (long exors, extensors, etc.). The patient should, for example, mobilize the ngers against increasing load by stabilizing the carpal and metacarpal bones in a neutral position and then more functionally by nishing in the symptomatic position. At rst, stabilization can be supported by a splint or taping. For real tendinopathy it is sometimes useful, in addition to progressive eccentric loading, to combine exercise with electrotherapy (laser, US, TENS) or ice. And, if the nociceptive input remains dominant, it may be possible to modulate its intensity by just crossing the hands over the midline! (The analgesic effect of crossing the arms) (G allace et al. 2011).
Cas e Study 6.1 Kind of d is ord e r This is a cas e example o Mrs I, a 56-year-old woman who, when as ked, ‘What do you eel is your main problem at pres ent? ’ replied ‘I s till cannot us e my hand properly; it s till hurts a ter my all onto it.’ This cas e s tudy highlights the key clinical eatures o wris t and hand dis orders , a model or identi ying movement impairments through detailed phys ical examination and the context o the us e o mobilization or manipulation in the rehabilitation proces s .
Are a s of s ymp toms Figure 6.60 s hows the us e o a ‘real s ize’ body chart to detail the exact location o the patient’s wris t and hand
3 72
pain and the re erral pattern. Us ing a larger body chart als o allows the therapis t to hypothes ize about the s ource o the s ymptoms in relation to anatomical s tructures .
Be ha viour of s ymp toms (ove r a 24-hour p e riod ) Mrs I explained that her main concern was not being able to us e her hand properly during neces s ary daily activities s uch as holding door handles and pus hing doors open. As a hous ewi e s he was als o having great di f culty pegging her was hing on the was hing line, amongs t other things . Mrs I was ed up becaus e s he could not complete her daily tas ks and s he was in a
P la n n in g th e p h ys ic a l e xa m in a tio n (P / E)
Cas e s tudy 6.1—cont’d Right hand ‘Sharp’ deep int 1
was bearable but became unbearable when s he tried to us e her hand.
Pas t his tory Mrs I could not recall having problems with the wris t in the pas t but had s u ered s everal bouts o ‘s pondylos is ’ in her neck. This was a bit s ti at pres ent, which was nothing out o the ordinary.
Sp e c ia l q ue s tions
Fig ure 6.60 • Right hand: area of symptoms.
Mrs I revealed that s he was generally in good health, with no recent weight los s . She had taken painkillers which helped a bit, but the wris t was s till very pain ul. There was no amily his tory o os teoporos is that s he was aware o and the doctor had not s ugges ted that s he have a bone s can. Overall, rom the his tory, the s ugges tion is o a local s o t tis s ue injury or bony injury o the wris t and carpus . There may be s ome contributory mechanis ms related to her neck dis order. This may warrant urther inves tigation.
P hys ic a l e xa mina tion General and s pecif c obs ervation great deal o pain or a ew hours a ter her attempts to carry out s uch activities . However, s he was happy that s he could us e her f ngers normally. She experienced mos t o her s ymptoms during the day when s he tried to us e her hand. Her s leep had not been dis turbed. This s ugges ts problems in the carpus , metacarpals or radioulnar region as the f ngers were unctioning normally. Both prehens ile and non-prehens ile unctions have been impaired quite s everely. The dis order als o s eems to be exhibiting a degree o irritability.
P re s e nt a nd p a s t his tory of s ymp toms Pres ent his tory The s ymptoms began s ix weeks prior to the date o the phys iotherapeutic cons ultation. Mrs I had been s hopping and tripped over a rais ed paving s lab. She ell on her outs tretched arm, was helped by pas s ers -by who phoned or an ambulance, and s he was taken to the local cas ualty department. An X-ray revealed no Colles ’ racture but the radiologis t s us pected a s caphoid racture. The wris t was put in a cas t or 10 days then re-X-rayed. No s caphoid racture was s een. On having the cas t removed Mrs I quickly s tarted to eel the wris t pain again and it gradually became more s evere over the next week or s o as s he tried to us e her wris t. Becaus e o this , the cas ualty o f cer decided to re-cas t the wris t or a urther three weeks . Mrs I was com ortable in the cas t. When it was removed in due cours e the wris t pain
On general obs ervation it was clear that Mrs I was reluctant to us e her right hand to its ull capacity, as revealed when s he removed her coat. Locally there was evidence o s welling having been pres ent around the carpus and wris t but no other abnormal eatures were evident.
Functional demons tration Mrs I demons trated that when s he tried to grip a door knob or handle s he was unable to do this without experiencing s evere pain in the wris t. On analys is o the unctional demons tration it was evident that wris t extens ion and orearm or wris t s upination were the main movement components . When the wris t was in its neutral pos ition Mrs I could grip s trongly and without pain, s ugges ting that the problem was in the wris t or carpus as s us pected, rather than the f ngers .
Brie apprais al Active wris t extens ion on its own was limited to 40° by the wris t pain; active wris t exion was limited to 70° by the wris t pain; orearm and wris t s upination reproduced the wris t pain at 85°. This clearly indicates that the wris t pain is reproduced mos t readily in wris t extens ion and s upination.
Screening tes ts The cervical s pine, s houlder and elbow were s creened. The elbow was cleared o any impairment. The s houlder was uncom ortable and s ti in the quadrant (peak)
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Cas e s tudy 6.1—cont’d pos ition and the cervical s pine was s ti into right rotation, right lateral exion and extens ion. In view o the nature o the injury on the outs tretched arm and the potential or impairment o the s houlder and neck to contribute to the dis order’s recovery, it would be es s ential to include treatment o thes e regions as a neces s ary part o rehabilitation. However, this was done in conjunction with treatment o the wris t and hand and has not been included urther in this cas e example. The neck, s houlder and hand components were treated s eparately.
Pas s ive movements The whole hand movement o extens ion to 40° reproduced Mrs I’s wris t pain. Di erentiation o wris t extens ion revealed that pain was reproduced with radiocarpal extens ion alone; extens ion o the midcarpal and carpometacarpal joints was much les s pain ul. Supination o the orearm and hand to 85° reproduced the s ame wris t pain. Di erentiation tes ting revealed that when the radiocarpal and in erior radioulnar joints were s upinated
more (and les s ) in the pain ul pos ition, the movements o the radiocarpal joint were much more (or les s ) pain ul than the radioulnar joint. The conclus ion to draw rom this proces s is that the pain appeared to be related to mechanical s tres s es impos ed on the radiocarpal joint, mos t likely the bones o the proximal row o the carpal bones . Other general wris t and hand movements were relatively pain ree. Further inves tigation o intercarpal movements revealed that the s ame wris t pain could be reproduced in the early part o the range o movement when the s caphoid was moved in an anteropos terior movement in relation to the lunate. The des ignated mobilization technique there ore was a grade II anteropos terior intercarpal movement o the s caphoid on the lunate with the des ired e ects o reducing the movement-related pain, increas ing the pain- ree range o wris t extens ion and s upination, and acilitating or complementing a home exercis e programme des igned to res tore ull unction o the wris t and hand.
Re erences Beghi E, Kurland LT, Mulder DW, Nicolosi SO : A brachial plexus neuropathy in the population of Rochester, Minnesota, 1970–1981, Ann N eurol 18(3):320, 1985. Butler DS: M obilisation o the N ervous System, Edinburgh, 1991, Churchill Livingstone. Corrigan B, Maitland G D: Practical O rthopaedic M edicine, London, 1983, Butterworths. G allace A, Torta DME, Moseley G L, Ianetti G D: The analgesic effect of crossing the arms, Pain 152: 1418–1423, 2011. G ifford LS: Pain, the tissues and the nervous system, Physiotherapy 84(1):27–36, 1998. H ofer A: Das A olter-M odell, München, 2009, Richard P aum Verlag. H oppenfeld S: Physical Examination o the Spine and Extremities, New York, 1976, Appleton Century Crofts. Jeangros P: T4-Syndrom. in: Klinische M uster in der manuellen Therapie,
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New York, 2011, G eorg Thieme Verlag, Stuttgart, pp 354-369. Kapandji IA: The physiology of the joints: annotated diagrams of the mechanics of the human joints. In The Upper Limb, vol 1, ed 5, Edinburgh, 1982, Churchill Livingstone. Kesson M, Atkins E: O rthopaedic M edicine: A Practical Approach, O xford, 1998, ButterworthH einemann. Maitland G D: N euro/musculoskeletal Examination and Recording G uide, ed 5, Adelaide, 1992, Lauderdale Press. Maitland G D, H engeveld E, Banks K, English K, editors: M aitland’s Vertebral M anipulation, ed 6, O xford, 2001, ButterworthH einemann. Moseley L, Zalucki NM, Wiech K: Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain, Pain 137:600–608, 2008.
Mumenthaler M: N eurologie 5, Au . Stuttgart, 1979, G eorg Thieme Verlag. Narakas AO : The role of thoracic outlet syndrome in the double crush syndrome, Annals o H and Surgery 9(5):209–214, 1990. Putz R, Pabst R, editors: Sobotta Atlas o H uman Anatomy, ed 14, 2006, Elsevier Urban & Fisher Publishers. Roston JB, Wheeler-H aines R: Cracking in the metacarpophalangeal joint, Journal o Anatomy 81:165, 1947. Upton ARM, McComas AJ: Double Crush in Nerve-Entrapment Syndromes, Lancet ii:359–362, 1973. WH O : International C lassi cation o Functioning Disability and H ealth, G eneva, 2001, World H ealth O rganization. Williams PL, Warwick R, editors: G ray’s Anatomy, ed 36, Philadelphia, 1973, WB Saunders, pp 802–1216.
Manag e me nt o f hip dis o rde rs
7
Di Addison
C H AP TE R C O N TE N TS
which are then weighted according to importance and accordingly treated. The clinical reasoning process utilized by the Maitland Concept provides a clinical tool to cope with this complexity.
Introd uc tion
375
Ap p lie d the ory
379
Evid e nc e s up p orting p ra c tic e
385
Sub je c tive e xa mina tion
385
P hys ic a l e xa mina tion
391
Tre a tme nt
417
Struc tura l s ourc e s
Ac tive te c hniq ue s
433
Local as well as distant structures capable of referring pain into the hip region are listed in Table 7.1. A knowledge of clinical patterns, differentiation tests and screening procedures will be necessary to distinguish between these structures.
Key words Clinical orthopaedics and related res earch dis orders , intra-articular dis orders , periarticular dis orders , one-component clinical orthopaedics dis order, multi-component movement dis order, functional dis order
Intro duc tio n Symptoms in the hip region may be caused by multistructural and multi-functional factors. A single pain may arise from different structures whereby associated functional factors (e.g. faulty movement patterns) may further contribute to the morphology, severity or chronicity of symptoms. Pathobiological processes also cause or in uence symptoms. H ence optimal management of the patient’s problem requires recognition of all causative components
Components of hip dis orders
Func tiona l c a us e s (c ontrib uting fa c tors ) These may be divided into movement dysfunctions or overload. 1. M ovement dysfunctions: According to Sahrmann (2002), faulty posture and dysfunctional movement patterns are not only the result of pain and pathology but may also cause these lesions. If the symptomatic structure alone is treated (with passive movement, for example) and the dysfunction or ‘cause of the cause’ (Maitland 1991) is disregarded, symptoms could well reoccur. In fact, in cases of minor instability or impingement, mobilizing gently in the direction of symptoms to decrease pain may meet with limited or short-lived success. If stronger mobilizing techniques progressing into pain are applied symptoms may suddenly increase. This is a clinical indication that 3 75
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Table 7.1 Components of hip disorders: the symptomatic structure(s)
Structures
Local sources
Distant sources
Joint
Hip joint including the labrum, and ligamentum teres
Lumbar spine Sacroiliac joint Pubic symphysis Coccygeal joint
Muscle, tendon
Gluteal muscles Piriformis Gemellii Obturatorii iliacus and psoas Tensor fascia lata Rectus femoris Sartorius adductors Pelvic oor muscles
Trigger point activity in distant muscles: Quadratus lumborum External obliquus Iliocostalis lumborum Tensor fascia lata Piriformis Gluteal muscles
Fascia, bursae
Iliotibial tract Trochanteric bursa Ilioinguinal bursa Ischial bursa Pectineal bursa
Abdominal fascia (athlete’s groin)
Neural structures
Ilioinguinal nerve (L1) Genitofemoral nerve(L12) Lateral femoral cutaneous nerve (L23) Femoral nerve (L2-L4) Obturator nerve (L2-L4) Sciatic nerve (L4-S1) Superior gluteal nerve (L4-S1)
Plexus lumbalis/lumbosacralis Spinal nerves/rami ventrali (L1-S3) Sympathetic trunk and ganglion
Viscera
Arteries (e.g. femoral) Lymph vessels
Aorta and iliac arteries (aneurysm) Deep vein thrombosis Abdominal and retroperitoneal pathology (hernia)
functional factors need be addressed. In Table 7.2 a number of disorders are listed where the functional cause assumes particular importance. 2. O verload or overuse per se may in time lead to degenerative change or stress fracture. If malalignment is also present then otherwise normal stresses may excessively load one part of the hip joint, the surrounding nerves or myofascial structures. Individuals working at heavy jobs (e.g. furniture movers) or individuals engaged in sports with poor technique or inadequate training procedures (e.g. running on hard surfaces) may subject their joints to overload. Similarly, nerve entrapments such as meralgia paraesthetica are reported to have contributing overload factors: obesity, the wearing of tight jeans and wide belts resulting in compression (Butler 1991). 3 76
P a thob iologic a l d is ord e rs A range of pathobiological disorders may contribute to movement disorders of the hip (Table 7.3). These disorders may be categorized as:
• Systemic disorders with spontaneous development of acute symptoms. H ere medical care is important. • Developmental and structural disorders: both dysplasia and Perthes’ disease may contribute to structural change and the development of femoroacetabular impingement (Fraitzl et al. 2007, Rab 1999, Friend & Kelly 2009, Li & G anz 2003), which in turn is said to be implicated in the development of degenerative osteoarthritis (G anz et al. 2003, Beck et al. 2005, Bardakos & Villar 2009). Where structural change is present, surgery may be the priority for treatment.
In tro d u c tio n
Table 7.2 Components of hip disorders: functional causes
Functional cause
Disorder
Hypermobility dysfunctions
Global muscle imbalance
Functional anterior or anteromedial impingement
Groin pain associated with hypermobile exion or combined exion-adduction movements (the high kicks of ballet and martial arts) resulting from a lack of deceleration force from antagonistic muscles such as the deep gluteus maximus or posterior gluteus medius (global stabilizers)
Functional posterior impingement
Buttock pain associated with hypermobile extension/abduction/external rotation movements due to impingement of the posterior labrum and posterior soft tissues. The superior gluteus maximus (global mobilizer) is overactive; the iliacus and the short adductors (global stabilizers) are inhibited
Iliotibial tractitis and/or trochanteric bursitis in exion
Discomfort or stretching/burning pain in the superior gluteus maximus muscle or it’s fascia (lateral hip) with restriction of exion or combined exion-adduction activities. Super cial gluteus maximus is overactive or shortened. Con ned sitting will produce unavoidable stretch in the muscle if the patient is unable to ex the lumbar spine (lack of knee room) or abduct the hips. Deep turns during skiing and lying on the affected side (compression of soft tissue) or non-affected side (stretching) may also irritate this condition
Iliotibial tractitis and/or trochanteric bursitis in extension
Lateral hip pain associated with repeated extension/rotation activities such as jogging. It results from an overactive tensor fascia lata (global mobilizer) pulling the iliotibial tract forwards over the trochanter. The posterior gluteus medius (global stabilizer) is inhibited. It may be aggravated by lying on the affected or non-affected side
Entrapment of the lateral femoral cutaneous and inguinal nerves
Lateral thigh or groin pain on sustained excessive exion particularly in obese individuals or those with wide hips, may cause nerve compression and irritation
Athlete’s groin
Pain may be widespread over the pubic symphysis, groin, medial thigh and sacroiliac joint or restricted to the falx region adjacent unilaterally to the pubic symphysis. Global stability dysfunction in the pelvic ring as a whole is often involved, associated with inadequate fascial covering in the falx region of the lower abdomen. Pain may be aggravated by forceful rotation movements, stop–go activities or forceful sit-ups
Ischial bursitis/bicipital tendinosus, bursitis, muscle tears (especially in the adductors, psoas and biceps femoris muscles and their associated bursae)
Local pain in the affected structures often associated with pelvic stability dysfunction in the presence of overactive hip muscles seeking to provide stability, particularly during forceful stop-go activities
Restrictive dysfunctions Degenerative osteoarthritis
Groin pain or generalized pain associated with weight-bearing (joint surface compression) and end-of-range activities (capsular tightness). Hence restrictions may be present in deep sitting, sitting with crossed legs and getting in and out of a car. In particular, multiple movement directions may be restricted rather than single directions
Excessive intra-joint gliding (minor instabilities)
Local muscle imbalance Inhibition of tonic activity in psoas, the gemelli and the obturatorii as a unit
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Table 7.2 Components of hip disorders: functional causes—cont’d
Functional cause
Disorder
Hypermobility dysfunctions
Global muscle imbalance
Anterior gliding dysfunction
Often unspeci c or sometimes sharp groin pain due to generalized synovitis or stretch / impingement of anterior structures. Joint blocking may occur if the femoral head remains in an anterior position so that normal coupling of posterior gliding with physiological exion cannot take place. Open-chain exion movements (e.g. during stair climbing) may result in labral, chondral and other soft tissue irritation, including iliopsoas tendinopathy. Inhibition of psoas (local stabilizer responsible for tightening the capsule and hence preventing it’s impingement) is one of the features of this dysfunction. During open and closed chain extension activities anterior structures will also be stressed. The patient may also avoid trunk movements involving hip lateral rotation in standing
Posterior gliding dysfunction
Buttock pain due to excessive posterior gliding within the joint. Flexion or exion/ adduction movements may be limited due to reactive inhibition and apprehension (fear of posterior subluxation). The patient may avoid sitting or squatting or sit on one buttock with the affected hip in extension over the side of the seat. Standing and lying supine with the affected hip in slight abduction and lateral rotation are preferred positions. It occurs often in association with trauma, e.g. dashboard injury or landing on a hard surface by long-jump
Lateral gliding dysfunction
Generalized pain or lateral pain standing on one leg with adducted (hanging) hip or when lying on the non-affected side. Tonic activity in psoas, gemelli and obturatorii as a unit is lacking. This condition may be found in combination with hip dysplasia
Table 7.3 Components of hip disorders: pathobiological processes Systemic disorders
Septic arthritis Rheumatoid arthritis Acute osteoporosis Paget’s disease Osteonecrosis Juvenile chronic polyarthritis Ankylosing spondylitis Crohn’s disease
Developmental disease and structural disorders
Perthes’ disease Congenital dysplasia Slipped femoral epiphysis Structural femoroacetabular impingement (FAI) Structural posterior impingement Note: structural FAI is caused by bony exostoses on the acetabulum or femoral neck (pincer or cam impingement respectively). Here groin pain is associated with restricted exion activities such as deep sitting, reaching forward in sitting, bending and squatting. Forced or powerful exion causes pain (Macfarlane & Haddad., 2010). Note: structural posterior impingement. Here groin pain is associated with hypomobile extension/ abduction/external rotation movements due to impingement of the anterior labrum and cartilage. This is due to a contra-coup levering of the femoral head forwards in the presence of a posteriorly blocked cam impingement. Posterior hip pain is also expected
Vascular disease
Femoral head necrosis
Traumatic lesions
Fractures of the femoral head, neck, acetabulum and labrum Subluxation Dislocation Contusions Femoral or inguinal hernia
Ap p lie d th e o ry
• Traumatic disorders where tissue healing times will affect dosage and progression of treatment. Utilizing the principles of the Maitland Concept, the therapist can decide which components of the problem deserve priority and which combinations of treatment measures are indicated.
Applie d the o ry Integration of s tructural and functional dis orders In order to organize and prioritize treatment the model in Figure 7.1 developed by the author may be useful. In this model, major categories of dysfunction are shown. These are determined by examining the amount of movement taking place
in the symptomatic joint in the main symptomatic direction. For example, the hip or a structure primarily related to hip movement produces symptoms on sitting, squatting or stair climbing. These exion activities as well as isolated hip exion would be assessed to determine whether or not the amount of movement is excessive or restricted according to generously standardized expected ranges of movement. 1. + M ovement dysfunction would indicate that the symptomatic movement is excessive or uncontrolled. This dysfunction may be subdivided into excessive physiological (or angular) movement and excessive accessory (or gliding) movement. • + Physiological movement dysfunction. H ere the physiological movement is uncontrolled allowing increased end-of-range movement (hypermobility). Excessive physiological movement is generally readily observable. If
Faulty posture or movement patterns, trauma, disease processes
+ Movement Accessory or translatory movements are excessive
Physiological or angular movements are excessive
Instability
Hypermobility
Often intra-articular damage
– Movement protection
Protective restriction in one or more directions
Often soft tissue damage (impingement, bursitis, fascitis)
– Movement restriction Accessory Movements are restricted
Physiological Movements are restricted
Joint blocking
Restricted movement due to painful muscular, articular, fascial or neural dysfunction
Restricted movement in a specific direction due to lack of coupled translatory movement
Low irritability
High irritability
Low irritability
Light pain early signs future risk faxtor
Severe pain
Receeding pain stiffening Stiffness in a neighbouring joint or in the opposite gliding direction in the same joint
Fig ure 7.1 • Integration of structural and functional disorders. Reproduced with permission from Addison (2002). 3 79
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neighbouring joints in the movement chain are also hypermobile, the hip may not become symptomatic as forces would be shared along the chain. H owever, if the neighbouring lumbar, sacroiliac and knee joints are stiff then repeated bending movements or forceful hip exion movements during sport may traumatize the hip leading, for example, to impingement of anterior soft tissues including the labrum. According to Martin et al. (2006), labral tears have been arthroscopically identi ed – although not in isolation – in 90% of mechanical hip pain. A number of authors link labral damage to the development of capsular laxity and vice versa (Schenker et al. 2005, Martin et al. 2006), suggesting that better end-range control of this movement may help reduce symptoms as well as recurrences. O ther dysfunctions linked to excessive physiological movement have been listed in Table 7.2. • + Accessory movement dysfunction. H ere the translatory or gliding movement is uncontrolled resulting in a variable and undependable centre of rotation. This will also affect physiological movement and may be experienced as a lack of ‘through’ range movement control; for example, if the patient attempts to stand on one leg with his hip joint in the ‘physiological’ neutral position (neutral exion/ extension, abduction/ adduction, medial rotation [MR] and lateral rotation [LR]), the hip ‘jerks’ or ‘wobbles’ and cannot remain still. These joints may not necessarily exhibit increased end-of-range movement but the ‘neutral zone’ has been shown to be increased (Panjabi 1992) with subsequent loss of a reliable ‘translational neutral position’ (midposition of three-dimensional translation movements). This may be referred to as ‘stability dysfunction’. In addition, excessive gliding may be associated with increased end-of-range movement in the normally coupled physiological direction. A certain amount of posterior gliding is coupled with hip exion. If this gliding is excessive the exion movement may also seem excessive. In fact, the actual angular movement in the joint may be restricted but the disturbed gliding produces a hinge-like gapping 380
movement and a seemingly increased exion. Alternatively, the condition may elicit protective reactions in the effected direction resulting in decreased range of movement. H owever, in both situations the increased shearing movements are detrimental to the cartilage as well as irritating to the synovium and are thought to contribute to joint effusion and, in time, osteoarthritis. These joints are classed as ‘unstable’. 2. − M ovement dysfunction due to protective reactions. In order to be placed in this category the condition must be ‘irritable’ according to the Maitland Concept de nition. In this case, the protective reactions in a single or multiple direction are considered initially necessary. Whether the symptoms are due to acute trauma, to overuse or abuse of the joint, correction of the symptomatic movement would be detrimental at this stage. O nce the irritability factor has been reduced, the condition may be reclassi ed into one of the other categories. 3. − M ovement dysfunction due to restriction. This dysfunction may be subdivided into restricted physiological (or angular) movement or restricted accessory (or gliding) movement. • − Physiological movement dysfunction. If speci c ranges of movement are not used, adaptive restriction may occur in time. Disuse may result from habitual patterns or protective reactions. H abitual patterns may be due to restricted movement in non-symptomatic neighbouring joints (see the arrow in Figure 7.1). In the case of pathological disorder (e.g. ankylosing spondylosis), protective reactions may be appropriate and some movement restriction unavoidable. In other cases, a restrictive pattern may remain because the patient failed to fully use the joint although the disorder was no longer irritable. • − Accessory movement dysfunction – the blocked joint. If gliding movement (e.g. anterior glide) is excessive in one direction it may in time become restricted in the opposite direction (posterior glide) (see the curve in Figure 7.1). Since hip exion is coupled with posterior glide, the exion may become restricted. Patients often
Ap p lie d th e o ry
describe a bursting feeling at end of range.
Mus cle clas s i cation and as s ociated mus cle imbalance Mus c le c la s s i c a tion Muscles may be generally classi ed into local stabilizers, global stabilizers and global mobilizers according largely to their biomechanical characteristics (see Table 7.4 and Box 7.1). The classi cation of lumbar and hip muscles is shown in Box 7.2.
Table 7.4 Biomechanical characteristics of global stabilizers and global mobilizers
Global stabilizers
Global mobilizers
One joint
Two-joint or multi-joint
Deep
Super cial
Direction of pull produces joint compression
Direction of pull: movement-orientated
Muscle length: long
Muscle length: long
Force vector + force lever optimal for joint compression (minimal muscle mass or muscle strength necessary)
Force vector + force lever optimal for large range of movement, speed, acceleration and joint distraction (large muscle mass/muscle force necessary)
Muscle bres are broad and take an oblique course (shock-absorbing)
Muscle bres take a linear course (strength is maximally directed)
Control of rotation – especially decelerating
Produce strong exion/ extension (largely aligned in the sagittal plane)
Control of physiological movement in a particular peripheral joint (responsible for selective movement) or the form of the curve in a vertebral section
Produces movement along the length of the movement chain and is therefore relatively non-selective
(Comerford & Mottram 2001)
Mus c le imb a la nc e a nd a s s oc ia te d d ys func tion Muscle imbalance and associated dysfunctions are illustrated in Figure 7.2. From this it may be postulated that pain due to excessive gliding movements in the hip (irrespective of whether physiological movements are hypermobile or restricted) will require better recruitment of the local stabilizers as treatment. For selective physiological movement in a joint it is important that the global stabilizers work ef ciently. If physiological hip movement is excessive due to inhibition of the global stabilizers with multi-joint global mobilizers dominating, then the hip – relative to other joints above and below along the movement chain – will move excessively. H ence hypermobility disorders require global stabilizer recruitment/ shortening and mobilizer inhibition/ lengthening. By irritable disorders the local stabilizers may be tonically inhibited (see ‘Motor Control’ below). H ere it is necessary that the capsule can expand to cope with excessive intra-articular swelling. Co-contraction or protection provided by the global muscles will ensure that the joint is temporarily spared. H owever, the joint will receive little proprioceptive input making it more dif cult to recruit the local stabilizers particularly if this situation is maintained once pain and swelling have subsided.
Box 7.1 Biomechanical characteristics of local stabilizers • • • •
•
•
One joint (s egmental) Deepes t mus cle layer – often with connections to the joint caps ule Mus cle length: very s hort (Mcgill & Norman 1993, Mcgill 1991) Direction of pull: mus cle bres don’t run in the direction of primary joint movement: • very little s hortening Poor leverage: des igned for compres s ion and trans lational control • little mus cle mas s es s ential Work cons tantly – independent of the movement direction
Adapted from Richardson et al. 1995.
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Box 7.2 Classi cation of lumbar and hip muscles Glob a l s ta b ilize rs
M. tens or fas cia lata M. rectus femoris M. s artorius M. gracilis M. piriformis M. gluteus maximus .(s uper cial bres ) Hams trings
M. obliquus internus and externus M. multi dus (s uper cial bres ) M. s pinales M. quadratus lumborum (lateral bres ) M. iliacus M. adductor brevis M. pectineus M. adductor. magnus M.gluteus medius + minimus M. gluteus maximus .(deep bres ) M. quadratus femoris
Loc a l s ta b ilize rs M. M. M. M. M. M. M. M.
Glob a l mob ilize rs M. M. M. M.
rectus abdominis longis s imus iliocos talis quadratus lumborum (medial bres )
trans vers us abdominis multi dus (deep bres ) intertrans vers arii inters pinales rotatores ps oas obturatorius internus + externus gemellus s uperior + inferior
Adapted from Bergmark (1989), Sahrmann(2002), Richardson et al. (1995), Comerford & Mottram (2001).
+ Movement
– Movement protection
Accessory or gliding movements
Physiological or angular movements are excessive
Local stabilizer inhibition
Global stabilizer inhibition Global mobilizer overactivity
Local stabilizer inhibition with global mobilizer overactivity (restriction in specific directions)
– Movement restriction Accessory
Physiological
Local stabilizer inhibition with global mobilizer overactivity resulting in
Global mobilizer overactivity or shortening/ passive muscular retriction/ fascial restriction
or additional joint restriction global stabilizer overactivity (restriction also in rotation: co-contraction)
passive blocking
Fig ure 7.2 • Muscle imbalance and associated dysfunctions. Reproduced with permission from Addison (2002).
Furthermore, if this strategy is maintained longer than necessary adaptive change may produce shortening of muscle (reactive and passive), joint capsules and fascia resulting in restricted physiological movement. 382
Excessive gliding movements in one direction may in time become xed in this particular direction. If local tissues (nerves and blood vessels) adapt to this new position then gliding in the excessive direction may no longer produce symptoms. The
Ap p lie d th e o ry
restricted gliding may then be responsible for symptoms: coupled physiological movement may be blocked producing symptoms of stiffness or ‘bursting’ at end of range.
Motor control For adequate motor control the appropriate muscle bre type should be recruited. All human muscles contain tonic and phasic muscle bres. Characteristics of these muscle bres are shown in Figure 7.3. For low-level activity (activities requiring approximately 25% of a maximal voluntary contraction) selective recruitment of only the tonic bres is necessary for stability. For high-level activity maximal tonic recruitment together with phasic bre recruitment is essential. Most activities in daily life require only tonic bre recruitment. If the phasic bres alone are recruited both low- and high-level activities will seem strenuous. In some individuals levels of tonic recruitment are poor. This may be related in part to an inactive lifestyle: proprioceptive input (increased through movement and the interaction with gravity in particular) helps recruitment of tonic bres. This lack of tone is often seen in the global stabilizers. The global mobilizers must then attempt to provide stability as the last line of defence. H owever, this will be largely inadequate as their levers are
unsuitable requiring an uneconomical use of phasic muscle bre recruitment. The presence of pathology also inhibits tonic bre activity in the local stabilizers and interferes with timing of their contraction. Pain or swelling have been shown to delay their activity (Stokes & Young 1984). This has consequences for treatment: if low-level activities are symptomatic, then tonic bre activity should be recruited. Strength training may be inappropriate. Symptomatic high-level activities will require phasic as well as tonic bre recruitment, i.e strength training.
Treatment principles For detailed information on the selection and progression of treatment techniques with passive mobilization see Chapter 1 of H engeveld and Banks (2014). The following suggestions summarized in Figure 7.4 integrate functional factors.
• If the disorder is irritable or severe and the pain mechanism is nociceptive, gentle passive accessory movement (particularly distraction and rotation techniques) may be used for pain modulation and to help in dispersing swelling. Protective deformities may temporarily be advantageous. Medication and rest – including the use of walking aids – may be necessary.
Phasic Muscle Fibres
Characteristics
Tonic Muscle Fibres
Metabolism
Oxidative
Oxidative-glycogenic
Glycogenic
Force
Small
Medium
Large
Slow
Delayed
Fast
Fatigue Fatigue % 90 -
Type IIa
Type IIb
90
90
50 0 0 1 2 3 4 5 6 60 Speed
6
0
Slow
Medium
60
0
3 Fast
Fig ure 7.3 • Muscle bre characteristics. After van den Berg 1999. 383
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+ Movement Accessory or gliding movements
– Movement protection
Physiological or angular movements
Tonically recruit Tonically recruit the Local and shorten the Stabilizer during Global Stabilizer and performance of the inhibit or lengthen symptomatic movement the Global (painfree correction Mobilizer during of the pattern) performance of the symptomatic movement (painfree correction of the pattern)
Gentle passive accessory movement electrotherapy etc medication rest
– Movement restriction Accessory
Physiological
Passive accessory mobilization techniques
Inhibition or lengthening of the Global Mobilizer, Trigger point techniques, fascial lengthening, etc.
Fig ure 7.4 • Integrated treatment principles. Reproduced with permission from Addison (2002).
• If the disorder is not irritable or severe, the following guidelines may help determine treatment priorities:
○ Where excessive physiological movement
○
○
(hypermobility) is found in the symptomatic direction active stabilizing exercise may be the treatment of choice (e.g. better endrange control of lateral rotation for speci c labral lesions, or athlete’s groin). If pain occurs during low-level activity, correcting the movement pattern by tonically recruiting and shortening the global stabilizer and inhibiting overactivity in the global mobilizer will help achieve a pain-free movement pattern. For excessive lateral hip rotation, for example, recruiting the anterior gluteus medius and minimus and the short adductors while inhibiting the piriformis and superior gluteus maximus may achieve this aim. If the hip is compensating with excessive movement for restriction in neighbouring joints these joints can be mobilized at some stage (e.g. excessive hip external rotation during a golf swing may compensate for lumbar spine or knee rotational restrictions). Where excessive gliding movement (minor instability) contributes to dysfunction in the symptomatic direction, pain-free tonic recruitment of the segmental stabilizers while maintaining normally painful positions and performing normally painful activities
384
○
○
may help restrain excessive gliding. Similarly, passive accessory mobilization in the opposite direction to pain may be necessary if this direction has become stiff. Where restriction in the coupled gliding direction is found to block the physiological movement, passive accessory joint mobilization, may be the treatment of choice. Because gliding and physiological movements are coupled (Matles 1975, Simoneau G , H oenig K Lepley J et al 1998 cited in Sims (2003), mobilizing an accessory movement such as posteroanterior glide may restore extension movement. Sims (2003) states that the migratory ‘up and out’ presentation of osteoarthrosis may lack longitudinal caudal motion whereas the medial migratory presentations may lack lateral gliding motion. Restriction in physiological movement may be helped by a combination of muscle lengthening, trigger-point techniques or fascial techniques, etc.
In restricted joints where compressive force is related to symptom production the use of compression may at some stage be incorporated into treatment. Maitland (1991) suggests that mobilizations with compression may stimulate synovial uid ow and improve cartilage nutrition, which may be important in the early stages of osteoarthrosis. The peripheral anterior surface of the femoral head is a common site of cartilage lesions (Bullough et al. 1973 cited in Sims 2003). Sims (2003) states that
S u b je c tive e xa m in a tio n
this area will contact in internal rotation and adduction and suggests that this may explain the bene cial effects of the hip exion–adduction technique. Where symptoms in the symptomatic direction are related to neural dysfunction, neural techniques may be appropriately incorporated into the treatment (for example, the femoral nerve test in prone knee bend).
Evide nc e s uppo rting prac tic e Patients with osteoarthritis are the most commonly referred single group for physiotherapy. Table 7.5 lists evidence-based recommendations for treatment. In the case of soft tissue injury (including labral injury), there is growing interest in the effects of neuromuscular training as opposed to stretching or strengthening training. Labral tears, for example, have been related to forceful external rotation
particularly in sports and activities such as golf, soccer and dancing. According to Martin et al. (2006), labral tears have been arthroscopically identi ed – although not in isolation – in 90% of mechanical hip pain cases. A number of authors link labral damage to the development of capsular laxity and vice versa (Schenker et al. 2005, Martin et al. 2006), suggesting that better end-range control of this movement may help reduce symptoms as well as recurrences. Some evidence largely from case reports is listed in Table 7.6 to support neuromuscular training and movement re-education (particularly the activation of the appropriate global stabilizers) for various hypermobility dysfunctions.
Subje c tive e xaminatio n In the subjective examination, ‘making features t’ (Maitland 1991) is important: a given hypothesis
Table 7.5 Evidenced-based interventions for osteoarthritis
Interventions
Result
Comments
Reference
Hip-strengthening exercises
Bene cial effect in reducing pain and improving function
Meta-analysis of nine studies
Hernández-Molina et al. 2008
Hip-strengthening exercises
Long-term effectiveness in reducing pain, improved self-reported and observed physical function
Systematic review: moderate evidence; results for hip and knee osteoarthritis combined
Pisters et al. 2007
Manual therapy, strengthening and mobilizing exercises
Reduction in pain, increase in passive range of movement, clinically meaningful improvement in function
Case series of seven patients
MacDonald et al. 2006
Exercise programme versus conventional medical treatment
Small positive clinical effect measured by the Harris hip pain scale‘ ‘up and go’ test and walking test
Moderate-quality RCT
Tak et al. 2005
Combination of passive mobilization and exercises versus exercises alone
Manual therapy and exercise ( exibility, strengthening and aerobic exercise) combination resulted in better outcomes regarding pain and functional activity
Moderate-quality RCT, high drop-out rate
Hoeksma et al. 2004
Exercises versus standard medical education
Exercise ( exibility, strengthening and aerobic exercise) resulted in better outcomes regarding pain and functional activity
Moderate-quality RCT
van Baar et al. 1998
Aquatic therapy versus standard medical education
Aquatic therapy proved superior in reducing WOMAC pain scores, and improving WOMAC physical function at 12 weeks; small bene t at 12 months; no signi cant effect at 18 months
Good-quality single blinded RCT; results for hip and knee osteoarthritis combined
Cochrane et al. 2005
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Table 7.5 Evidenced-based interventions for osteoarthritis—cont’d
Interventions
Result
Comments
Reference
Aquatic therapy versus a waiting control group
Aquatic therapy improved visual analogue pain score on movement and WOMAC pain scores, stiffness function and physical function at six weeks; sustained at 12 weeks
Moderate-quality single blinded RCT; results for hip and knee osteoarthritis combined
Hinman et al. 2007
Aquatic therapy versus tai chi versus a waiting control group
Aquatic therapy and tai chi improved WOMAC function scores; aquatic therapy alone reduced WOMAC pain scores
Moderate-quality RCT; results for hip and knee osteoarthritis combined
Fransen et al. 2007
Cane in the contralateral hand
Reduction in hip pain and improvement in function
RCT
Neumann 1989
RCT = randomized control trial, WOMAC = Western Ontario and McMaster Universities Arthritis Index (Royal Australian College of General Practitioners (2009), Cibulka (2009), Zhang et al. (2008))
Table 7.6 Evidence-based interventions for hypermobility syndromes
Disorder
Treatment
Study design
Results/comments
Reference
Piriformis syndrome
Hip-strengthening exercises and movement re-education
Case report
Pain free Lower extremity function scale questionnaire Score from 65/80 to 80/80 Improved kinematics during step-down test
Tonley et al. 2010
Hamstrings injury
Gluteus maximus strengthening and neuromuscular training
Case report
Eliminated exercise-associated cramping Improved hip extensor strengthDecreased activity of hamstrings during terminal swing
Wagner et al. 2010
Hamstrings injury
Progressive agility and trunk stability (neuromuscular control exercises) versus progressive stretching and strengthening
Prospective randomized comparison of two rehabilitation programmes
A progressive agility and trunk stabilization exercise programme is more effective than a programme emphasizing isolated hamstring stretching and strengthening in preventing injury recurrence during the rst year of return to sports
Sherry & Best 2004
Athletic groin injury
Strengthening adductors and abdominal muscles versus passive local applications
High-quality RCT
At seven months: Active group: 79% return to sport without residual symptoms Passive group: 14%
Hölmich et al. 1999
Athletic groin injury
Compressive shorts
Retrospective controlled trial
Improved subjective pain scores; no improvement in functional performance
McKim and Taunton 2001
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Table 7.6 Evidence-based interventions for hypermobility syndromes—cont’d
Disorder
Treatment
Study design
Results/comments
Reference
Athletic groin injury
Combination of passive joint mobilization and active exercise
Case series No control group
Directly following treatment: Return to sport without symptoms 77% Long-term results: moderately high risk of recurrence
Jansen et al. 2008
Athletic groin injury
Strengthening adductors and abdominal muscles versus controls
Good-quality RCT
Some positive short-term effects; No signi cant long-term effects
Ekstrand & Ringborg 2001
Osteitis pubis
Local passive therapy (electrostimulation, ultrasound, cryomassage) and progressive physical loading
Poor-quality case report
Symptom free after 10 weeks
Rodriguez et al. 2001
Athletic groin pain
Rest, trunk stabilization exercises and graded return to sport
Case series
At ve mths: 63% return to sport (41% without symptoms) At two years: 74% unchanged
Verrall et al. 2007
RCT = randomized control trial
should take on form from different pieces of information in the subjective examination and con rmation should be sought in the physical examination.
Main problem (‘Ques tion 1’) Understanding the main problem from the patient’s point of view allows the focus of assessment and treatment to be effectively directed. Initially, the kind of disorder being presented is established: 1. Patients may present with the main problem being pain which signi cantly limits daily life activities. This gives some indication of the severity or irritability of the disorder. H owever, perceived pain should bear some relation to perceived disability – high reports of pain coupled with only limited disability may represent a psychosocial risk factor hindering recovery to full function. Similarly low pain reports may be linked to considerable disability. In fact, where patients have learned to live with their pain by restricting activity, the irritability factor may be underestimated. Such patients may have some pain or discomfort after walking, gardening or driving a car, but if they prolong the activity, they may suffer acute exacerbation
2. Patients may report limitations in daily activities due to large restrictions of range of motion with associated pain being less of a problem. Soames (2003) lists the required range of movement for speci c activities as follows: • Walking on level surfaces: 30° exion, 10° extension, 5° abduction, 5° adduction, 5° medial rotation, 5° lateral rotation • Ascending stairs: 65° exion, 5° extension • Descending stairs: 65° exion, 5° extension • Sitting: 90° exion • Tying shoelaces: 50° exion. Magee (2008) gives differing measures. This can be due to a number of factors such as stair and sitting heights and according to the degree of compensation allowed in surrounding joints. For example, tying shoes requires 50° exion (Soames 2003) but 120° exion according to Magee. It would be expected that Soames’ patients are compensating to a greater extent in neighbouring joints. H owever, this increased load on surrounding structures may injure them. In fact, the whole lower quadrant movement system is at risk of becoming symptomatic if further impairment of joint mobility occurs. Focusing on what is important for the patient can be expedient: in assessing movement, many 387
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dysfunctions will inevitably be found with some having no connection to the present problem. H owever, an ef cient exercise programme should be streamlined to correct the dysfunctions which are relevant. For example, if sitting and squatting are the main problem, exion should be assessed in detail for painful restrictions or for painful excessive uncontrolled movement (particularly in relation to other joints in the movement chain). The quality of associated accessory movements during exion may also be relevant. Correction of the restricted or excessive exion movement pattern during sitting or
squatting activities may thus be the aim of treatment with a speci c selection of passive movement techniques, exercise, etc. used to achieve this aim.
Areas of s ymptoms (body chart) Typical pain patterns and associated hip dysfunctions are delineated in Figure 7.5. The ‘C ’ sign – demonstrating the area of pain by holding around the hip with ngers anteriorly and thumb posteriorly – is thought to be indicative of intra-articular pathology,
Anterior 1. Athlete`s groin • Abdominal fascia and pubic symphysis lesions 2. Groin pain • labral tears • anterosuperior cartilage lesions, loose bodies • impingement (structural/functional) 1 • necrosis of ligt teres, 2 • coxa saltans (snapping of the psoas tendon, labrum) 3 • nerve entrapment (ilioinguinalis etc.) 4 3. Anterior thigh • Intra-articular damage, femoral nerve injury 5 4. Knee • Intra-articular hip damage, often chronic 5. Shin • acute and severe intra-artic hip structures, • nerve injury
Lateral • Iliotibial tractitis • Trochanteric bursitis • Coxa saltans • Piriformis trigger point • Gluteus medius lesion • Meralgia paraesthetica
1 Medial • Adductor tandinosus (often in association with athlete`s groin) • Oburator nerve entrapment (medial thigh to knee) • Femoral nerve entrapment (medial distal thigh extending to lower leg and foot)
Fig ure 7.5 • Symptom areas associated with hip movement disorders. 388
2
Posterior 1. Buttock pain • Posterior impingement • Posterior labral tear • Piriformis syndrome • Superior gluteal nerve impingement 2. Posterior Thigh • Ischial bursitis • Hamstrings tendinosus • Coxa saltans: semitendinosis tendon frictioning over the ischial tuberosity
S u b je c tive e xa m in a tio n
for example, arthritis, cartilage and labral damage, necrosis of ligamentum teres, etc. (Magee 2008). In particular, pain due to degenerative arthritis is often dull deep and aching frequently referring vaguely to the anterior thigh and/ or knee (Wroblewski 1978, Poppert & Kullig 2011). Lesions in the anterior superior labrum-cartilage zone are likely to be con ned to the groin and to be sudden, sharp and stabbing on weight bearing (Liebold et al. 2010). If radiating tingling or burning pain is present, nerve entrapment should be considered while in amed fascia (iliotibial tract) may also produce burning pain or a ‘numb feeling’ without true numbness being present. Painful snapping and weakness should also be noted. Importantly, other sources such as the sacroiliac joint, lumbar spine, the neurodynamic system and, at times, the thoracic spine may refer symptoms in the same or similar body areas. Pain in the buttock with or without posterolateral thigh referral is typical for L4 nerve root lesions or disc problems. Moreover, physiotherapists working in direct contact should consider possible visceral or vascular sources of the symptoms which may require the attention of a medical practitioner.
Behaviour of s ymptoms H ere information can be sought regarding irritability of the disorder, clinical patterns and tests providing parameters for reassessment. C linical patterns may be related to: 1. Disorders: ○ according to Maitland et al. (2001), an intra-articular disorder with a degree of in ammation might be suspected if symptoms are more constant in their behaviour, are perceived as deeply localized and more restricting in daily life activities and if regular changes in resting positions are needed. Systemic in ammatory disease such as rheumatoid arthritis may occur more spontaneously and episodically with morning pain and stiffness lasting longer than an hour. Concomitant multi-joint involvement is a feature. 2. Structures:
○ labral tears: here forceful rotation is often ○
involved and may be accompanied by a clicking sensation in the groin. Tendinopathies and muscle lesions: pain is clearly pinpointed by the patient and
reproduced on stretching or contracting the muscle or during stop-and-go activities (Agre 1985). ○ Joint surface of the hip: reproduction of symptoms occurs during weight-bearing activities, particularly sustained standing. Sudden loading of the joint surface, for example, when moving out of sustained positions such as sitting may also produce symptoms (Arnold et al. 1972). ○ Capsular tightness: end-of-range movements may aggravate symptoms. ○ Fascia: under tension, burning or prickling symptoms may occur. ○ Nerve entrapment (e.g. meralgia paraesthetica): burning pain during the night is typical. 3. Movement dysfunctions: ○ The symptomatic activity and subsequent analysis of the movement direction together with type and area of symptoms (Fig. 7.5) will help establish the dysfunction. It also helps the therapist focus on the movement direction requiring careful assessment and later treatment. Direction-speci c aggravating activities with their typical movement dysfunctions are listed in Table 7.7. The establishing of easing factors is as essential as establishing aggravating factors: what has the patient learned so far or what does the patient instinctively do to relieve the symptoms? The patient may, for example, grasp around the leg, shake it or rub it, which may be indicative of a movement disorder stemming from the hip. If the patient intuitively grasps the back or shifts the body weight to the other buttock during sitting, a lumbar spine or sacroiliac movement disorder may be present.
His tory Where trauma is involved, the mechanism of injury may give important information:
• Before posterior gliding dysfunction (see Table 7.7) is implicated, a dashboard or similar injury with posterior subluxation of the hip is sought in the history. • A fall on the outside of the trochanter may result in lateral soft tissue injury, medial cartilage injury (Magee 2008) or fractures depending on the forces involved. Particularly in 389
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Table 7.7 Direction-speci c aggravating activities and typical movement dysfunctions
Activities
Dysfunctions
Flexion and exion/adduction activities For example, deep sitting, sitting with crossed legs, reaching forward in sitting, standing from sitting, bending forward, squatting, getting in and out of a car, skiing, high kicks
Anteromedial impingement Structural femoroacetabular Impingement (pincer or cam) Anterior gliding dysfunction Posterior gliding dysfunction Degenerative osteoarthritis Iliotibial tractitis and/or trochanteric bursitis in exion Entrapment of the lateral femoral cutaneous and inguinal nerves
Extension and extension/ lateral rotation and weightbearing activities e.g. sustained standing, walking, Nordic walking, jogging, running, high kicks on the weightbearing leg, golf swing and other turning activities in standing
Iliotibial tractitis and/or Trochanteric bursitis in extension Functional posterior impingement Structural posterior impingement Anterior gliding dysfunction Degenerative osteoarthritis
Side lying For example, provides compression on the lower side and adduction/medial rotation stretch on the upper side
Trochanteric bursitis/ iliotibial tractitis Lateral gliding dysfunction
older patients, osteoporosis may be considered. Musculotendinous lesions are often directly related to trauma (Agre 1985). If no obvious trauma is present:
• Repeated forceful end-of-range loading may play a role in the more insidious overall development of symptoms. This is typical in sports and activities such as football, martial arts, ballet and golf. 390
• An assumed relatively sudden onset due to twisting movements on one leg may be indicative of labrum tears (Sims 1999) or local muscular or ligamentous lesions. H amstring injury, for example, is likely to result from rapid forceful change from concentric to eccentric activity (Verrall et al. 2001) and is likely to reoccur in 34% of cases (Croisier 2004). • O veruse and misuse of the structures may lead to the gradual development of symptoms over time with little initial interference in daily life activities. G ardening in excessive hip exion (jackknife position) rather than sharing the exion proportionally over the knee and spine will gradually stress the hip region. • Walking with poor motor control at the hip is a further example (G unn 1980, Weinstein 1992). If excessive hip movement compensates for stiffness or pain in neighbouring joints, the course of symptoms over time may shift from an initially painful lumbar spine or knee to the hip. The importance of correcting compensations as soon as pain and injury levels allow is therefore clear. Moreover, an originally one-component movement disorder in the lumbar spine, pelvic or hip region may develop into a multi-component disorder over the course of years (Ekberg et al. 1988). For example, poor motor control of the pelvic girdle may be associated in time with a symptomatic sacroiliac joint and pubic symphysis, with irritation of weak abdominal fascia and associated adductor tendinosis (H ölmich 1999). Similarly, complications while giving birth may produce pelvic muscle lesions and asymmetries affecting the entire hip and pelvic region producing long-term debilitating symptoms (H ungerford et al. 2004). Such factors need consideration when planning the rst one to three sessions of the physical examination. In the past history, developmental disorders may have been diagnosed. Dysplasia (particularly in girls) has been shown to develop in later life into femoroacetabular pincer impingement and Perthes’ disease or epiphysiolysis of the femoral head (more often in boys) can develop into femoroacetabular cam impingement (G anz et al. 2003). These structural impingements may initially present as intermittent groin pain which increases with high demands on the joint or from activities such as sustained deep sitting (Leunig & G anz 2005).
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Special ques tions and medical s creening ques tions
• In particular where symptoms do not seem to be directly related to movement functions these screening procedures must be taken into consideration.
• As well as routine information about the patient’s general health, weight loss, radiographic ndings, medication intake, etc., particular attention needs to be given to screening questions regarding urogenital and intestinal functions (Boissonnault 1995, G oodman & Snyder 2000).
Phys ic al e xaminatio n Box 7.3 provides an overview of examination procedures of the hip and related structures. Detailed information on some test procedures is given below.
Box 7.3 Physical examination of the hip Ob s e rva tion
P a lp a tion
•
•
Pres ent pain
Func tiona l d e mons tra tion/te s ts •
Including differentiation of movement components
Brie f a p p ra is a l Ac tive move me nts • •
• • •
•
Gait analys is In s tanding: • weight bearing: F, E, Ab, Ad, MR, LR • s wing movements : F, E, Ab, Ad, MR, LR • trunk movements : as s es s ment of relative exibility of the movement chain Step-down tes t • Going up and down s teps Squatting In s itting: • – exing knee to ches t • – exing knee to oppos ite s houlder (F/Ad) • – exion trunk to feet • –MR, LR In prone and s upine lying, including overpressure: • in s upine: F, MR and LR in 90° F; Ab, Ad • in prone: E, MR, LR
Mus c le te s ts • •
Is ometric tes ts Mus cle length tes ts (global s tabilizers and global mobilizers )
Sc re e ning of othe r s truc ture s in ‘p la n’ • • • •
Lumbar s pine Sacroiliac joint provocation tes ts Thoracic s pine If applicable: neurodynamic tes ting (or in later s tage during pas s ive tes ting)
• •
Tendernes s of ins ertions of periarticular mus cle groups Nerves (e.g. lateral femoral cutaneous nerve in area of inguinal ligament) Burs ae
P a s s ive move me nts If applicable, including s ubs equent reas s es s ment procedures • Neurodynamic tes t procedures : • SLR • PKB • s lump • modi ed PKB in s ide lying (‘s ide lying s lump’), including modi cations for lateral femoral cutaneous nerve, obturator nerve • Movement diagram of relevant active tes ts : F, in 90°F; MR or LR, Ab, Ad • Phys iological movements : • F/Ad (if all tes ts negative s o far: add MR, LR; compres s ion through femur s haft; and through collum femoris ) • in F: do Ab; F/Ab as part of pas s ive circumduction movement • In E: do Ab, Ad, MR or LR; or combinations of three directions (es pecially E, Ad, MR)
Ac c e s s ory move me nts As a p p lic a b le : ceph and caud; , , , , in various hip pos itions Add compres s ion (cephalad and medial), where applicable
Sta b ility te s ts • Anterior, pos terior and lateral gliding dys function Check cas e records etc. Highlight main ndings with as teris ks Ins tructions to patient at end of s es s ion
391
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Obs ervation The physical examination from posterior, both sides and anterior usually starts with a general observation of:
• Posture • Muscle contours – indication of visible wasting, in particular gluteal muscles, quadriceps, abdominal muscles
• The skin and local soft tissues for possible changes in swelling, thickening or colour • Structural impairments. See Box 7.4 for alignment measures. Considerable controversy exists regarding measures of ideal alignment (Klein-Vogelbach 1983, Kendall & McCreary 1993, Sahrmann 2002, Magee 2008). Nevertheless a frame of reference is necessary. This should be
Box 7.4 Physical examination: observation of posture Ante rior vie w •
Pelvis – neutral lateral s hift (mid-pos ition of the heels , pubic s ymphys is , umbilicus and s ternum s hould be vertically aligned): • neutral rotation in the trans vers e plane (a line joining the toes – if the feet are s ymmetric – s hould be parallel to a line joining the anterior s uperior iliac s pines ). This meas ure is important to pick up mas ked rotation in the hip • neutral cranial/caudal tilt in the frontal plane • Femur/hip – thigh s hould appear to be vertical. (The femoral s haft is then obliquely orientated and 10° externally rotated) • Patella/knee/tibia – patella aligned over the s econd metatars al (patella s hould lie in the frontal plane) • longitudinal axis of the thigh and lower leg are vertical and in direct alignment • Foot – s econd metatars al 8°–10° externally rotated Functional knee bend: in order to examine alignment more accurately, the patient may be as ked to bend the knees s lightly (Fig. 7.6). Here it is eas ier to determine whether or not the patella lies in a line with the axis of the s econd metatars al.
La te ra l vie w (b oth s id e s ) The plumb line follows a line from approximately midway through the trunk, the greater trochanter, s lightly anterior to a midline through the knee and anterior border of the lateral malleolus and the anterior s uperior iliac s pine (ASIS) is in the s ame vertical plane as the s ymphys is pubis . •
• •
Pelvis – line joining ASIS (anterior s uperior iliac s pine) and PSIS (pos terior s uperior iliac s pine) is horizontal or tilted 5° anteriorly: this s hould corres pond with a neutral lumbar s pine curve and neutral hip and knee joint angles Knee – neutral extens ion Foot – longitudinal arch neutral
392
Fig ure 7.6 • Posture – sagittal view.
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Box 7.4—cont’d P os te rior vie w: •
Pelvis – neutral rotation in the trans vers e plane (a line joining the heels s hould be parallel to a line joining the anterior s uperior iliac s pines )
•
•
Knee – knee fold horizontal (or not more than 10° higher laterally). A greater deviation is indicative of s tructural or functional rotary malalignment Foot – s ubtalar joint neutral in the frontal plane
Adapted from Klein-Vogelbach 1983, Kendall & McCreary 1993, Sahrmann 2002 and Magee 2008.
Table 7.8 Indications implicating speci c structural dysfunctions
Indications
Related structural dysfunctions*
Apparent hip medial rotation often compensated with knee external rotation and toeing out
Femoral antetorsion
Apparent hip lateral rotation with toeing out
Femoral retrotorsion
Prominence of the trochanter with hip adduction
Coxavarus
Lack of prominence of the trochanter and a vertical thigh
Coxavalgus
Flexion or medial rotation in exion are restricted
Femoroacetabular impingement(pincer/cam)
‘Bow legged’ deformity from the knee joint or the tibial bone respectively
Genu varum and tibia varum
‘Knock knee’ deformity: 1. If hip medial rotation is present and its correction brings the foot from pronation into neutral, a functional deformity may be present 2. If correction of hip medial rotation brings the foot from an apparently pronated position into inversion and the tibia from an oblique position into a vertical one, restricted subtalar eversion or restricted forefoot pronation may be suspected 3. If correction of the knee or hip is not possible a structural dysfunction in the knee or hip is likely to be present
Genu valgum
Lateral tibial torsion may present with toeing out or hip medial rotation if the foot position is straight
Tibial torsion
With the medial borders of the feet together and the knees in ideal alignment over the second toe, the trochanter is higher on one side
Structural leg length difference
*Note: see Sahrmann (2002) for a description of these conditions.
interpreted generously and deviations should be considered in association with symptoms. Correction of postural malalignment should follow to determine whether or not:
• A protective reaction is present (as indicated by increase in symptoms), • Malalignment is causing symptoms (a reduction in symptoms with correction) or
• Malalignment is at all associated with the patient’s disorder (no change in symptoms). If correction is dif cult to perform due to tightness, then joint restriction or structural dysfunction may be present in the area of perceived tightness. Special tests or radiographs may be needed if structural dysfunctions are suspected. Refer to Table 7.8 for clinical tips on indications implicating speci c structural dysfunctions. 393
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Functional demons tration tes ts • Present pain – before performing any tests to •
•
•
•
reproduce symptoms, the presence and level of paint need be determined. Functional demonstration – the patient is asked to demonstrate an activity which provokes their main pain. This activity may serve as an asterisk. Performing differentiation procedures, where more stress is added to or removed from the individual movement components, may indicate which components are contributing to the main symptom. This is an essential principle of the Maitland Concept. In the case of a painful snapping hip where the patient has dif culty locating the source of symptoms, provocative movements may be performed by the patient while the therapist palpates over the lumbar spine, the sacroiliac joint, the trochanter laterally, the groin and the tuber ischiadicum in turn to locate the click and determine the source. It should be clear whether testing is aimed at differentiating the painful structure (source of symptoms) or the causative dysfunction: ○ In a painful deep-sitting position, a decrease of pain after tilting the patient’s ilium posteriorly may implicate the hip rather than the lumbar spine as the source of pain. ○ During a step-down test alleviation of hip symptoms with a wedge under the medial heel or longitudinal arch may implicate subtalar or forefoot dysfunction as the cause or contributing factor for the development of pain in hip structures. Brief appraisal – following differentiation tests, a brief appraisal or re ection on ndings so far helps determine whether test procedures may be continued as planned, or if adaptations of the examination are necessary.
Active movements During active tests various parameters are being assessed and recorded. These are:
• willingness and ability to move • quality of movement, including muscular recruitment patterns • range of active movement • any symptom response. 394
Ga it a na lys is G ait analysis is an essential test procedure for patients presenting with hip, knee or foot symptoms. Deviations should be corrected to determine if a direct relationship with the patient’s symptoms is present. O bservation takes place from the side, from anterior and from posterior. Precise observation of the different phases of the stance and swing phase is frequently necessary (Whittle 1991):
• Stance phase:
○ ○ ○ ○ ○
heel contact foot at mid-stance heel off toe off (phase between heel off and toe off – ‘terminal rocker’). • Swing phase:
○ mid swing ○ end swing. Depending on the symptoms and the functional demonstration tests, the patient may be asked to walk in a different manner, for example:
• • • • • • •
Walking forwards, sideways, backwards Speed Small steps, large steps Walking with crossed legs Walking on toes, heels Walking on medial or lateral borders of the feet Walking in internal or external rotation of the legs.
Careful observation of any asymmetries of the various determinants of gait is essential (Whittle 1991, Rose & G amble 1994), for example:
• • • • • • •
Transfer of centre of gravity of body Pelvis, trunk, foot, knee and hip movements Stride length, stride width Foot position Cadence of movement, frequency of steps Stance time and stride time Average walking speed.
If movement dysfunctions of the hip are suspected, special attention needs to be given to the following aspects:
• During stance – Duchenne sign, Trendelenburg sign, transfer of the pelvis over the leg, especially rotation, adduction and extension
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movements. According to G rimaldi et al. (2009), a Duchenne sign results from wasting and weakness of the gluteus medius posterior while with the Trendelenburg sign a hypertrophied but excessively long gluteus medius can be expected. • At the end of the stance phase – extension, adduction and medial rotation movements (Klein-Vogelbach 1983). • If forward walking seems normal, walking backwards, or variations of gait with big steps or with crossed legs may give a more detailed indication of gait deviations due to pain, stiffness or muscular impairments.
Active tes ting in s tanding This is important if the patient’s symptoms are related to standing or walking, providing more functionally useful information about quality of movement and the ability to move than tests in lying.
We ight b e a ring (Fig. 7.7) The physiotherapist guides the patient in moving the pelvis over the leg, producing exion/ extension, adduction/ abduction and internal and external rotation movements or any combinations of these. These movements may frequently reproduce the symptoms or reveal impaired movements, for example, discomfort with lateral rotation in combination with extension (often indicative of excessive anterior gliding or stress into anterior joint structures); loss of range of motion with adduction; difculties with balance; or a diminished recruitment pattern of gluteus medius and minimus muscles during abduction movements.
Te c hniq ue • Patient starting position: Standing on the affected leg, holding the physiotherapist’s shoulder to maintain balance. • Therapist starting position: Standing in front of the patient. • Localization of forces: Physiotherapist holds onto the left and right crista iliaca of the patient’s pelvis. • Application of forces: Therapist guides the patient’s pelvis in F/ E direction, Ab/ Ad direction and MR/ LR direction.
Fig ure 7.7 • Active movements in weight bearing.
This test may be progressed to perform balance reactions on one leg, which is more provocative.
Swing move me nt Similar to the tests in weight bearing, the physiotherapist supports the patient’s hands to maintain balance. The patient produces active swinging movements of the affected leg towards exion, extension, abduction, adduction, medial and lateral rotation. In the athlete or dancer high kicking movements may follow. Pain in association with hypermobile ranges may indicate anterior or posterior functional impingement in the swing or stance leg respectively whereby restricted movement and pain may suggest structural impingement or joint blocking due to restriction of accessory movement. These results may guide the physiotherapist towards more detailed testing for these dysfunctions. 395
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Trunk move me nts : a s s e s s me nt of re la tive e xib ility of the move me nt c ha in Standardized active examination of recruitment patterns of the trunk and leg muscles during trunk exion, extension, lateral exion and rotation provides information for the later treatment of contributing factors. H owever, these tests are not necessarily a compulsory procedure in the rst examination session. Examining the ‘relative exibility’ of different structures in the movement chain (Sahrmann 2002) can indicate where stiffness from neighbouring structures needs to be considered in treatment. Recruitment patterns are also analysed during other active test procedures.
Ste p -d own te s t (Fig. 7.8) Stepping down from a small height with the test leg above will quickly reveal hip problems on the weight-bearing side. In the presence of weak abductors the hip clearly adducts and medially rotates or deviations of the trunk over the affected side are evident.
Ge tting up a nd d own s te p s Assess height of steps, distance to steps, quality and range of the movement. The patient who ascends with the trunk leaning forward and the lumbar spine and hips in excessive exion must strenuously pull his centre of gravity upwards using considerable work from the quadriceps of the proximal leg. H ere the knee is loaded to a greater degree than necessary and the hip extensors are working in a more lengthened position. A more economical pattern would be to thrust from the opposite leg using the calf muscles to a greater extent.
De s c e nd ing s te p s Follow the same procedure as outlined for the stepdown test.
Sq ua tting The patient may be asked to hold onto the treatment plinth to maintain balance and to squat down to the onset of pain or as far as capable. Careful observation with correction of any deviations during the movement is essential: abduction and lateral rotation of the hip often occur in order to avoid the impingement position; retraction rotation of the pelvis may be pain-producing due to the extra adduction demanded here. Signs of apprehension should also be noted (e.g. patients with posterior gliding dysfunction may be fearful of squatting). If the weight shifts to the affected side, the hip here is in greater exion and adduction (the cause of the dysfunction may be excessive exion or adduction) while shift of weight away is a typical protective reaction. O bserve if the patient reaches the end position on the toes or on the heels. Squatting on the toes suggests greater involvement of the knees in comparison to the hips (in the exion direction) while squatting with feet at requires comparatively greater exion stress on the hips and lumbar spine.
P rogre s s ion of the e xa mina tion
Fig ure 7.8 • Step-down test showing excessive hip adduction and medial rotation. 396
Rocking over may be used as a progression of the examination. The physiotherapist stands behind the patient to give support to the trunk and guides the patient back and forth from toes to heels, while holding the patient’s knees. As another progression of examination procedures, the patient may be asked to oscillate in the end-of-range squat position.
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Active tes ting in s itting Many patients have dif culty with leg movements in sitting (e.g. putting on socks, getting out of a car). The following active tests in sitting may irritate, for example, an anterior impingement (groin pain) or in ammatory or tight iliotibial tract (trochanteric and lateral thigh pain), etc.:
• Flexing the knee to the chest • Flexing the knee to the opposite shoulder (F/ Ad movement) • Flexion of the trunk towards the feet • Adduction or abduction of the thigh • Medial rotation, lateral rotation of the thigh Note: if the patient habitually sits with the pelvis posteriorly tilted and cannot correct the pelvic position to neutral, the superior gluteus maximus may be overactive or shortened or the joint may be restricted. To differentiate, the knees may be placed minimally further apart and the patient again asked to correct the pelvic position. If correction is now possible tightness or overactivity in the super cial gluteus maximus is implicit; if correction is not possible then the joint is stiff.
Active tes ting in s upine and prone pos itions , including overpres s ure The main physiological movements of the hip (particularly the movement associated with the most painful direction) should be examined in detail. O verpressure is added at the end of range if symptoms have not as yet been reproduced. A benchmark of appropriate range of movement for every direction would help de ne whether the movement tested is normal, hypermobile or restricted. H owever, the literature shows tremendous variation (American Academy of O rthopaedic Surgeons (1966) – Joint Motion (based on the research of four different committees), Kendall and McCreary (1993), Sahrmann (2002), Magee (2008), KleinVogelbach (1983), H oppenfeld (1976), Kapandji (1988)). Variation is due to a number of factors, for example: • Lack of clarity as to whether active or passive range is being described • Differences in starting position – exion has been described with the lumbar spine at on the plinth, with the patient’s hands under the
spine to maintain the lordosis and from the patient’s resting position • Lack of clarity as to whether the end position is representative of stretch tolerance or muscle stiffness (Mens et al. 2006). H owever, in looking for dysfunction a single measures of ideal range is not as important as de ning the extreme measures denoting hypermobility or restriction. H ence for every active movement described below an upper and lower measure is given based on extremes described by the authors above. Flexion range, for example, is given as 110°– 125°. A range af 90°–95° would be clearly restricted (especially in the presence of an abnormal end-feel on overpressure) and a exion range of 140° would clearly be hypermobile (especially if accompanied by a lack of decelerating resistance at the end of range). Measures between 95° and 110° would need to be considered more critically. The test sequence below is followed by a detailed description of tests:
In s up ine • • • • •
Flexion. Medial and lateral rotation in 90° exion. Lateral rotation in supine. Abduction. Adduction.
In p rone • Extension. • Medial and lateral rotation.
In four-p oint kne e ling • Flexion.
In s itting • Medial and lateral rotation.
Ac tive hip e xion in s up ine (Fig. 7.9) • Indication: Pain during exion activities. • Patient starting position: Supine with the patient’s hands under lumbar spine (neutral lordosis). • Test: The patient performs one-sided active hip exion with a bent knee. The therapist observes 397
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○ During exion the hip moves spontaneously
Fig ure 7.9 • Active exion.
for deviations into abduction, adduction or rotation. • If there are no deviations hip exion may be de ned as follows: ○ 110°–125° – acceptable ○ > 125° – hypermobile (inhibited deep gluteus maximus) ○ < 110° – reactive inhibition due to pain (if due to excessive posterior gliding apprehension may be present), or overactive/ shortened superior gluteus maximus. • Differentiation: the patient repeats the test in slight abduction (approximately 5 cm deviation laterally):
○ if further exion takes place then a
○
shortened superior gluteus maximus is presumed to be responsible for the restriction; if exion remains the same then restriction is due to a shortened posterior capsule or blocked joint: a) restricted posterior gliding (femoral head is too far anteriorly); b) restricted lateral gliding (femoral head lies too deep in acetabulum).
Deviations • Deviations in other planes of motion during the test should be corrected so that exion range may be assessed accurately. The pain reaction is observed to assist in determining the dysfunction: ○ During exion the hip moves spontaneously into abduction. If on correction range of movement decreases and/ or pain in the groin increases, a protective reaction is present and indicates avoidance of an anteromedial impingement site. If correction is dif cult due to resistance and trochanteric pain is present, the super cial gluteus maximus may be overactive/ restricted causing friction symptoms. 398
into adduction. If on correction range of movement increases and/ or groin pain decreases, anteromedial impingement due to excessive adduction in exion is indicated. Spontaneously the impingement site is not avoided. This may be because the movement pattern is so ingrained in the CNS or the pain is not suf ciently annoying or severe. This habitual movement pattern should then be sought in other daily activities. It indicates inhibition or lengthening of gluteus medius and quadratus femoris (global stabilizers) and an overactivity or shortening of the tensor fascia lata or the long adductors (global mobilizers).
Additional manoeuvre • Repeat active exion as above with the knee extended to assess hamstrings length and neural involvement: ○ 80°–90° – normal hamstrings length, good neurodynamics.
Fle xion in four-p oint kne e ling • Patient starting position: Four-point kneeling with neutral lordosis, knees and feet together, feet over edge of plinth. • Test: The patient shifts weight from the hands on to the knees rocking backwards in the direction of the feet without losing the lumbar lordosis. As soon as the lumbar spine begins to move the patient is asked to stop and the range of hip exion is measured: ○ 110°–125° – acceptable ○ > 125° – hypermobility: there is greater relative exibility in the hip in comparison with the lumbar spine in the exion direction due to an inhibited or lengthened deep gluteus maximus (global stabilizer) ○ < 110° – restriction due to stiff joint structures or muscle stiffness (e.g. super cial gluteus maximus). • Differential diagnosis: Repeat the test with the knees slightly apart and the feet together. If more exion is now possible in the hips then the super cial gluteus maximus was the cause (the muscle restriction is relieved as a result of hip lateral rotation, with little change to the joint).
P h ys ic a l e xa m in a tio n
A
B
Fig ure 7.10 • A Medial rotation in 90° exion. B Lateral rotation in 90° exion.
• If the same degree of exion movement occurs then the joint is stiff (posterior capsular restriction).
Comparison o hip f exion test in supine and our-point kneeling 1. If hip exion is more restricted in supine than in four-point kneeling (e.g. supine 90°, four-point kneeling 110°), then anterior gliding dysfunction may be the cause: the femoral head is anteriorly positioned and cannot glide suf ciently posterior to allow normal movement. In four-point kneeling posterior gliding is helped by the weight of the body on the femoral head. In addition, slight soft tissue resistance in supine may be less signi cant in 4 point kneeling allowing more movement. 2. If hip exion is greater in supine than in four-point kneeling, consider posterior gliding dysfunction. The patient may exhibit greater apprehension and hence movement restriction in kneeling.
Me d ia l a nd la te ra l rota tion in 90° e xion (Fig. 7.10) • Indication: Pain during rotation activities. • Patient starting position: Supine with the hip and knee in 90° exion and the patient’s hands under lumbar spine (neutral lordosis).
• Test: The patient performs active medial and lateral rotation. H ip rotation may be de ned as follows in medial rotation: ○ 30°–45° – acceptable ○ > 45° – hypermobile (inhibited posterior gluteal muscles or quadratus femoris) ○ < 30° – shortened capsule or structural femoral acetabular impingement (FAI), particularly if extremely restricted. • Differentiation: if medial rotation is much greater when tested in neutral exion/ extension (e.g. supine with the lower extremity resting on the plinth or in prone lying), then FAI is implicated (Ames & H eikes 2010, Enseki et al. 2010). This is because bony exostoses on the femoral neck or acetabulum will block movement in exion but not in extension.
La te ra l rota tion • Test: H ip rotation may be de ned as follows in lateral rotation: ○ 40°–60° – acceptable ○ > 60° – hypermobile (inhibited anterior gluteal muscles) ○ < 40° – shortened capsule or overactive/ shortened piriformis.
Me d ia l a nd la te ra l rota tion in s itting • This is an alternative test position for rotation testing in 90° exion. 399
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La te ra l rota tion in s up ine (re la tive e xib ility te s t) (Fig. 7.11) • Indication: Pain during rotation activities involving trunk rotation away from the test side. • Patient starting position: Supine with the thigh resting on the plinth; the knee is extended; the patient’s hands under the lumbar spine (neutral lordosis). • Test: The patient performs active lateral rotation as far as possible without movement of the anterior superior iliac spines or exion of the knee. H ip rotation may be de ned as follows: ○ 30°–45° – acceptable ○ > 45° – hypermobile (iliofemoral ligament laxity – Philippon & Schenker 2005, Kelly et al. 2007) ○ < 30° – restricted hip movement. • N ote: If the hip is restricted in lateral rotation but the patient requires a greater range of movement he may compensate by laterally rotating at the knee. The knee must therefore ex slightly in order to rotate. Therefore:
○ if the knee exes slightly and laterally rotates
○
before 30°–35° of hip lateral rotation is reached, then the knee is relatively more exible than the hip; if the knee remains extended but the hip rotates further than 40°–45° then the hip is more exible than the knee in this direction.
Ab d uc tion in s up ine (Fig. 7.12) • Indication: Pain during activities involving abduction.
Fig ure 7.12 • Abduction in supine.
• Patient starting position: Supine with the patient’s hands under lumbar spine (neutral lordosis); both legs are parallel and 90° to a line joining the anterior superior iliac spines. • Test: The patient performs active abduction as far as possible without movement of the anterior superior iliac spines:
○ 30°–50° – acceptable ○ > 50° – hypermobile (one joint adductors ○
inhibited or lengthened) < 30° –hortened capsule or tight two-joint adductors.
Ad d uc tion in s up ine (Fig. 7.13) • Indication: Pain during activities involving
Fig ure 7.11 • Lateral rotation showing relative exibility in hip and knee. 400
adduction. • Patient starting position: Supine with the patient’s hands under lumbar spine (neutral lordosis); the test leg lies 90° to a line joining the anterior superior iliac spines; the opposite leg is exed at the knee with the foot resting level with the outside of the knee on the test side. It may be necessary for the therapist to hold this leg. • Test: The patient performs active hip adduction as far as possible without movement of the anterior superior iliac spines:
P h ys ic a l e xa m in a tio n
○ 10°–15° – acceptable ○ > 15° – hypermobility (inhibited iliacus)
or excessive anterior gliding (see stability tests) ○ < 10° – shortened capsule or overactive/ shortened rectus femoris and/ or tensor fascia lata. • Differentiation: repeat the test in slight abduction. If there is less restriction the tensor is implicated. • N ote: O bservation of range, general quality and symptom reaction may be augmented by assessment of recruitment patterns of gluteus maximus, hamstrings and lumbar erector trunci muscles.
○ If symptoms are reproduced, further
differentiation may follow using overpressure applied in turn to the hip, sacroiliac joint and lumbar spine.
Fig ure 7.13 • Adduction in supine.
○ 10°–30° – acceptable ○ > 30° – hypermobile (one joint abductor ○
Me d ia l a nd la te ra l rota tion in p rone (Fig. 7.15) • Indication: Pain during rotation activities. When
inhibited or lengthened – gluteus medius and minimus) < 10° – shortened capsule or tight tensor fascia lata.
Exte ns ion in p rone (Fig. 7.14)
•
• Indication: Pain during extension activities. • Patient starting position: Prone lying with the
•
lumbar spine in neutral lordosis; the knee on the test side is in 90° exion; the therapist palpates the anterior superior iliac spines. • Test: The patient performs active hip extension without a change in position of the anterior superior iliac spines:
•
•
• Fig ure 7.14 • Extension in prone.
used in conjunction with rotation tests in exion it may con rm structural impingement as described above or length changes in piriformis. (Piriformis is a lateral rotator in hip extension but a medial rotator when the hip is exed.) Patient starting position: Prone lying with the hip and lumbar spine in neutral position, knee on the test side exed to 90°. Test: The patient performs active medial and lateral rotation. Medial rotation: ○ 20°–45° – acceptable ○ > 45° – hypermobility (inhibited posterior gluteus medius) ○ < 20° – shortened capsule or overactive/ short piriformis. Lateral rotation: ○ 30°–45° – acceptable ○ > 45° – hypermobile (inhibited anterior gluteus medius, gluteus minimus) ○ < 30° – shortened capsule or overactive/ short tensor fascia lata/ iliotibial tract. N ote: a 10° difference in medial and lateral rotation is allowable. 401
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A
B
Fig ure 7.15 • A Medial rotation in prone. B Lateral rotation in prone.
• Change in rotation function of the buttock muscles at approx. 60°/ 70° exion: ○ in 0° exion – only the anterior gluteus medius and gluteus minimus are medial rotators (global stabilizers) ○ in 90° exion – most of the gluteal muscles are medial rotators including piriformis (a global mobilizer). • N ote: test results of ranges of motion for rotation can be misleading if anteversion or retroversion are present. • Earlier, Craig’s test for anteversion/ retroversion was used in association with rotation testing. H owever, research conducted by Souza and Powers (2009) shows that this very popular clinical test exhibits only moderate agreement with MRI measures. Although shown to be substantially reliable and more accurate than at X-rays (Ruby et al. 1979), the test’s clinical use is questioned due to the wide con dence interval (11.8°) found. A description of this test has thus been omitted. H owever, Souza and Powers’subjects were American adults where obesity played some role whereas the much earlier research involved young English boys. H ence the test should be accurate when assessing individuals with a small body mass index: when the greater trochanter is easily palpable. 402
• N ote: Femoral antetorsion may be suspected if – simultaneously – medial rotation is excessive and lateral rotation is strongly diminished. H owever, an MRI is essential for accurate de nition.
Mus cle tes ts Is ome tric te s ts Isometric tests are performed if muscular lesions are suspected. They need to be combined with other provocation tests such as palpation of the speci c muscle to localize tender spots. H owever, further differentiation tests may still be needed to discount the muscle. Mens et al. (2006) found that pain during forceful isometric adduction in patients with sportsrelated groin pain signi cantly decreased in 68% of patients when the test was repeated using a stabilizing pelvic belt. Moreover, hip adduction force increased more than expected in 39% of cases with the belt. In these cases they suggest that adductor tendinosus was not responsible for pain. Rather, structures in an unstable pelvic ring (sacroiliac joint, pubic symphysis, abdominal fascia) are thought to be injured during load transfer from trunk to lower extremity. In this sense, Verrall et al. (2005)
P h ys ic a l e xa m in a tio n
described three pain provocation tests involving isometric adduction which, when positive, demonstrate a high likelihood for the athlete having MR-detected marrow oedema in the pubic bone around the symphysis area. See also Chapter 7 on pelvic girdle pain in H engeveld and Banks (2014). N ote: if muscle signs are present in conjunction with joint signs, it is often useful rst to treat the joint signs and then utilize those isometric tests that reproduce the symptoms as reassessment parameters. It is conceivable (Mens et al. 2006) that uncontrolled movements in an unstable pelvic ring may not only harm tendons but that increased tension in surrounding muscles may also stress joints making adductor tendinosis an integral part of an overall groin pain syndrome involving different symptomatic structures. (Biedert et al. 2003, Ekberg et al. 1988 and Albers et al. 2001).
Mus c le le ngth te s ts
not required and the contraction can be maintained for a minimum of 30 seconds without fatigue/ cramping/ tremor) • A correct movement pattern also during the eccentric return to the starting position • A lack of pain.
Ilia c us (Fig. 7.16) • Indication: Excessive hip extension, functional posterior impingement, recurrent hamstring lesions. • Patient starting position: Sitting with the lumbar spine in neutral lordosis, the thigh supported and the feet hanging. • Instruction: The patient is asked to pull the lower stomach in and bend the hip as far as possible without losing the trunk position. • Test:
○ Active and passive range are approximately the same. The therapist tests passive
The reader should refer to the sections on muscle classi cation and associated muscle imbalance on pages 381–382.
• These tests may be performed after establishing the status of joint movements. • In the presence of hypermobility or a lack of normal build-up of resistance at end range in the test direction, the global stabilizers are generally tested for inability to actively shorten. G lobal mobilizers are tested in the presence of restriction in the symptomatic direction. H ere inability to release or lengthen is evaluated. • As an apparently overactive or shortened muscle may indicate reactive protection of neural tissue, it can be advantageous to test mechanosensitivity to neurodynamic procedures beforehand.
Glob a l s ta b ilize rs A good test result is reached if, while supporting the weight of the lower extremity against gravity, the muscle demonstrates:
• Maximal shortening (the active end-range position of the joint is relatively equal to the passive end-range position) • Tonic recruitment (the contraction feels effortless and breathing remains normal; extra feedback from the therapist or surroundings is
Fig ure 7.16 • Iliacus test. 403
C H AP TE R 7
○
○
Manag e me nt o f hip dis o rde rs
movement by supporting the ilium with one hand and attempting to increase hip exion with the other. No dysfunctional movement pattern is present, for example: – leaning backwards – lumbar exion (posterior pelvic tilt) – lumbar extension (anterior pelvic tilt) – lumbar und pelvic rotation clockwise (overactive quadratus lumborum) – hip lateral rotation (overactive sartorius) – hip medial rotation (overactive tensor fascia lata) – weight transfer to the contralateral side (overactive quadratus lumborum or iliocostalis) – knee exion and hip extension (overactive hamstrings) – co-contraction of all global hip muscles. The contraction is easily held for 30 seconds without fatigue or tremor.
De e p glute us ma ximus (Wa gne r e t a l 2010) (Fig. 7.17)
the oor with the feet. The patient may grasp the sides of the plinth. • Therapist position: Standing facing sideways on the non-test side, with one hand placed under each of the anterior superior iliac spines and her distal foot under the patient’s foot on the non-test side. • Instruction: The patient is asked to pull the lower stomach in, contract the buttock muscles and slide the foot backwards along the oor as far as possible without changing pressure on the therapist’s hands or pushing on her foot. If the patient achieves this, the far knee should then be bent to 90°, again without changing the other parameters. When 90° knee exion is reached, the patient extends the hip towards the ceiling as far as possible. • Test:
○ Active and passive range (~ 10–15°) are
○
• Indication: Excessive hip exion, anterior impingement. • Patient starting position: Prone lying with the trunk on the plinth, the lower extremities over the distal end with knees bent; lumbar spine in neutral. No pressure should be applied against
○
compared by the therapist stabilizing the ischial tuberosity with one hand and attempting to increase hip extension with the other. The difference should be small. Dysfunctional movement patterns are sought: – lumbar extension or shearing movement in the spine – lumbar rotation – cramping or dominance of the hamstrings. The contraction is held for 30 seconds.
P os te rior glute us me d ius (Fig. 7.18) • Indication: Excessive hip adduction and medial
Fig ure 7.17 • Deep gluteus maximus test. 404
rotation, anteromedial impingement, iliotibial tract problems. • Patient starting position: Side lying with the test side above and the pelvis in neutral (a small towel may be placed under the waist); the trochanters lie vertically in the same plane; the lower leg bent; the upper leg straight with the hip in neutral exion/ extension and full lateral rotation. • Therapist position: Standing behind the patient monitoring the patient’s position. • Instruction: The patient is asked to pull the lower stomach in, contract the buttock muscles and lift the leg in the direction of the ceiling keeping the pelvis still, the trochanters over one another, the leg in line with the body and in full rotation towards the ceiling.
P h ys ic a l e xa m in a tio n
Fig ure 7.18 • Posterior gluteus medius test.
• Test:
trochanters lie vertically in the same plane; the lower leg bent; the upper leg straight with the hip in neutral exion/ extension and full medial rotation. • Therapist position: Standing behind the patient monitoring the patient’s position. • Instruction: The patient is asked to pull the lower stomach in and lift the leg in the direction of the ceiling keeping the pelvis still, the trochanters over one another, the leg in line with the body and in full medial rotation with the heel pointing towards the ceiling. • Test:
○ Active and passive range are compared by
○ Active and passive range are compared by
○
stabilizing the ilium with one hand and attempting to increase hip abduction with the other. The difference should be small. Dysfunctional movement patterns are sought: – hip exion or medial rotation (overactive tensor fascia lata) – posterior pelvic rotation backwards (overactive tensor fascia lata – trunk lateral exion (compensating with trunk muscles).
Ante rior glute us me d ius a nd minimus (Fig. 7.19) • Indication: Excessive hip adduction and lateral rotation, anterior labral tears, iliotibial tract problems. • Patient starting position: Side lying with the test side above and the pelvis in neutral (a small towel may be placed under the waist); the
Fig ure 7.19 • Anterior gluteus medius and minimus test.
○
stabilizing the ilium with one hand and attempting to increase hip abduction with the other. The difference should be small. Dysfunctional movement patterns are sought: – hip extension or lateral rotation (overactive super cial gluteus maximus) – posterior pelvic rotation forwards (overactive super cial gluteus maximus) – trunk lateral exion (compensating with trunk muscles).
Hip a d d uc tors : p e c tine us , a d d uc tor b re vis , longus a nd ma gnus a nd q ua d ra tus fe moris (Fig. 7.20) • Indication: Athletic groin pain, recurrent adductor tendinosis. • Patient starting position: Side lying with the test side below and the lumbar spine and pelvis in neutral (a small towel may be placed under the waist); the trochanters lie vertically in the same plane; the lower leg is straight with the hip in neutral exion/ extension and full lateral rotation; the upper leg is exed 90°/ 90° with the thigh parallel to the plinth, toes resting lightly on the plinth.
Fig ure 7.20 • Adductor test. 405
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Manag e me nt o f hip dis o rde rs
• Therapist position: Standing behind the patient monitoring the patient’s position. • Instruction: The patient is asked to lift the lower leg in the direction of the ceiling keeping the pelvis still, the trochanters over one another, the leg in line with the body and the heel towards the ceiling. • Test:
• Patient starting position: Supine with pelvis in •
•
○ Active and passive range are compared by
○
stabilizing the ilium with one hand and attempting to increase hip adduction with the other). The difference should be small. Dysfunctional movement patterns are sought: – hip medial rotation – lumbar lateral exion – cranial pelvic tilt.
•
•
neutral, hip exed to 90°, knee bent. Alternative patient starting position: Sitting with lumbar spine and pelvis in neutral, acromion vertically aligned with the ischial tuberosity, hip and knees in 90° exion, feet hanging freely. Instruction: The patient is asked to extend the knee as far as possible maintaining the lumbar spine in the neutral position. Test result: The knee extends to the benchmark position of ‘knee exion 10°’ without change in proximal joint position(i.e. anterior pelvic tilt and increase of lordosis). N eural differentiation: Slump test in sitting.
Glob a l mob ilize rs
Sup e rior glute us ma ximus /iliotib ia l tra c ts (s e e Wa gne r e t a l 2010) (Fig. 7.22)
• A good test result is reached if, in the
• Indication: Disorders related to restricted hip
lengthened position, a benchmark of hip or knee movement is reached.
Ha ms trings (Fig. 7.21) • Indication: Disorders related to restricted hip exion particularly with the knee straight, weak deep gluteus maximus, sway back posture, recurrent hamstrings lesions.
exion particularly in sitting; inability to sit with the hips adducted or without a back support or without holding on to the front of the seat, iliotibial tract problems resulting from rotational activities in deep exion. for example, ski turns. • The test is carried out exactly as described for active hip exion in four-point kneeling. H ere range of movement is assessed for restriction with the benchmark of 110°–120°.
Te ns or fa s c ia la ta in s ta nd ing (Fig. 7.23) • Indication: Disorders related to restricted hip extension, adduction lateral rotation (e.g. iliotibial tract problems, anterior gliding dysfunction). • Patient starting position: Standing with the back against the wall, knees straight; feet hip-width apart and 5–7 cm from the wall. • Instruction: The patient posteriorly tilts the pelvis moving the lumbar spine towards the wall. • Test result: The lumbar spine and lower thoracic spines are at on the wall.
○ Dysfunction: if the spine cannot lie at Fig ure 7.21 • Hamstrings test. 406
the hip exors or the lumbar longissimus and iliocostalis may be overactive or short.
P h ys ic a l e xa m in a tio n
Fig ure 7.23 • Tensor fascia lata test in standing.
Mod i e d Thoma s ’ te s t (Sa hrma nn 2002) (Fig. 7.24) • Indication: Disorders related to restricted hip
Fig ure 7.22 • Superior gluteus maximus/iliotibial tract test.
○ Differentiation: 1. Repeat the test with hip and knees bent: if attening is not possible –longissimus and iliocostalis are overactive or short or the lumbar joints stiff; if attening now occurs, the hip exors are overactive or short. 2. Repeat the test with the knees straight but the feet far apart; if attening is now possible the tensor fascia lata is overactive or short.
extension, adduction lateral rotation (e.g. iliotibial tract problems, anterior gliding dysfunction, anterior impingement). • Patient starting position: Standing with the backs of the mid-thighs in contact with the end of the plinth and near to the edge of the plinth on the test side. With the therapist supporting the legs, the patient rocks back on to the plinth. The neutral lumbar lordosis position is now located as follows:,the therapist rolls the patient’s pelvis away from her using both legs as a lever. The therapist’s proximal hand is now placed under the lumbar spine and the pelvis rotated back again. Using the legs as lever exion and extension movements of the spine are produced until it just rests against the therapist’s hand. O nce located, the patient is asked to maintain the lordosis by grasping 407
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Manag e me nt o f hip dis o rde rs
the hip in this position the patient is asked whether the end-feel is similar to the end-feel experienced when overpressure is applied to the metacarpophalangeal joint in extension (indicates capsule) or when overpressure is applied to the nger, metacarpophalangeal and wrist joints simultaneously (indicates muscle, i.e. iliacus).
Mod i e d ob e r te s t: te ns or fa s c ia la ta (s e e Fe rb e r e t a l 2010, Milne r e t a l 2010) (Fig. 7.25) Fig ure 7.24 • Modi ed Thomas’ test.
around the proximal thigh on the non-test side and xing its position throughout the test. The therapist’s proximal hand is now placed over the anterior superior iliac spine to monitor its position; the distal hand grasps the posterior proximal tibia and adducts the hip until the medial femoral condyle lies in the midline of the body. • Instruction: The patient is asked to slowly lower the thigh towards the plinth as far as it will go without losing the knee exion position (90°) or the hip or lumbar spine positions. The therapist monitors these positions. • Test result: The thigh should come to rest again the plinth representative of 10°–15° hip extension.
○ Dysfunction: The thigh fails to reach the ○
○
plinth: overactive/ shortened rectus femoris, tensor fascia lata, iliacus or capsule. Differentiation: repeat the test with: 1. The knee extended – if the plinth is reached or the thigh moves more in its direction then resistance from rectus femoris was responsible for this percentage loss of original extension. 2. The knee extended and hip abducted if the plinth is now reached rst then resistance from tensor fascia lata was responsible for the extra difference in extension range. If the plinth is still not reached then resistance from iliacus or the capsule was responsible. After applying overpressure to
408
• Indication: As for Thomas’ test. • Patient starting position: Side lying with the test side above. The right and left trochanters lie vertically in the same plane; the lower leg bent; the test hip is in neutral exion/ extension, full abduction and full lateral rotation with the knee in a few degrees of exion. The patient’s waist is held pressed against the plinth (in lumbar lateral exion). • Therapist starting position: Standing behind the patient. With the proximal hand stabilizing the pelvis and the right lower arm supporting the weight of the leg in a cradling position (hand proximal to the knee), the therapist leans in the direction of the pelvis. • Instruction: The patient is asked to actively maintain waist contact while allowing the leg to slowly sink in the direction of the plinth. The therapist simultaneously bends in the knee to allow the leg to sink. • Test result: H ip adduction 10° with the heel contacting the plinth (males) or 2.5 cm above (females). If this benchmark is not reached then the tensor fascia lata is overactive or short.
Fig ure 7.25 • Modi ed Ober test.
P h ys ic a l e xa m in a tio n
Re c tus fe moris (Sa hrma nn 2002) (Fig. 7.26) • Indication: Restricted hip extension. • Patient starting position: Single-leg stance on the non-test side; lumbar spine and hip in neutral. • Instruction: The patient is asked to ex the knee on the test side without changing the position of the proximal joints. • Test result: Benchmark of 120° knee exion should be reached.
M p iriformis (Tonle y e t a l 2010) (Fig. 7.27) • Indication: Excessive hip lateral rotation. • Patient starting position: Supine, with the hip exed to approximately 85°, the knee in 90° exion passive adduction to R1, light compression. • Therapist starting position: Standing at the side of the plinth with her distal foot resting on the plinth on the far side of the non-test leg adjacent to the knee. The therapist holds the thigh in contact with her trunk, the patient’s heel is supported on her distal hand and her
Fig ure 7.27 • M. piriformis test.
thigh. The therapist adducts the hip using weight transfer to the point where the anterior superior iliac spine is about to move. This hip position is stabilized using minimal shaft compression and the hip is carefully laterally rotated using the patient’s lower leg, which rests on the therapist’s thigh, as a lever. • Test result: Lateral rotation to approximately 45°. Less range indicates piriformis overactivity or shortness.
Ad d uc tors (Fig. 7.28) • Indication: Restricted hip exion/ abduction/ lateral rotation.
Fig ure 7.26 • Rectus femoris test.
Fig ure 7.28 • Adductors – length test. 409
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Manag e me nt o f hip dis o rde rs
• Patient starting position: Supine, the lumbar spine in neutral, the non-test leg extended on the plinth. O n the test side the hip is exed to approximately 45°, the knee is in 90° exion with the foot resting on the plinth adjacent to the opposite knee. • Instruction: The patient is asked to let the knee fall outwards as far as possible without movement of the anterior superior iliac spines or foot position. • Test result: Benchmark of 45°–50° lateral rotation is reached without loss of proximal joint positions. Less range indicates adductor overactivity or shortness.
Screening of other s tructures in ‘plan’ It is essential to examine the possible involvement of other components to the patient’s symptoms and movement disorder. These components may be examined in the rst session; however, as they also include passive test procedures with subsequent reassessment tests of the main physical asterisks, it is suggested that these screening tests be considered in the planning of the second and third treatment sessions.
Fig ure 7.29 • Slump in side lying.
For a detailed description of the screening tests see Butler (2000) and Maitland et al. (2001). As possible contributing factors to the movement disorder of the hip and pelvis region, the knee joint and foot complex frequently need quick screening of their alignment, mobility and recruitment patterns.
• Lumbar spine: Flexion, extension, rotations. If
•
•
• •
indicated, lumbar quadrant. PAIVMs, including subsequent reassessment of the main physical asterisks so far. Sacroiliac provocation tests such as F/ Ad with compression, Patrick’s test (FABERE sign), anterior and posterior tilts, passive accessory movements including subsequent reassessment. N ote: As F/ Ad with compression is also an important procedure for hip movement disorders, it is often useful to complete the hip examination with the relevant passive tests prior to the screening procedures of the sacroiliac joints. Thoracic spine: Extension, rotations, PAIVMs, including subsequent reassessment. N eurodynamic tests: straight leg raise (SLR), prone knee bend (PKB), slump, slump in side lying (Fig. 7.29), including modi cations to assess obturator or lateral femoral cutaneous nerves. They may be performed during the passive test procedures and, if indicated, followed by reassessment procedures. 4 10
Palpation Palpation of the periarticular structures may take place in various phases of the examination process:
• At the beginning of the physical examination, as one of the rst test procedures. This may be particularly indicated if in ammatory signs are being investigated. The ndings can be monitored during the subsequent active and passive test procedures as a precautionary measure. • Before passive examination tests, when the ndings can be used as comparable signs in reassessment procedures. • After passive examination tests. The following aspects may be palpated:
• Bony landmarks such as the iliac crest, anterior superior iliac spine, greater trochanter, ischial tuberosity and tuberculum pubis. The hip joint may be palpated deeply just below the inguinal ligament lateral to the femoral artery.
P h ys ic a l e xa m in a tio n
• Temperature and swelling. As the hip joint is placed deeply under the muscles, synovial swelling may be appreciated as a vague sensation of fullness or tenderness. A synovial cyst may track anteriorly to present as a swelling in the groin and needs to be differentiated from, for example, a femoral hernia, a saphenous varix, an arteriovenous stula, a psoas abscess and an iliopsoas bursitis (Corrigan & Maitland 1983). • Femoral artery and inguinal lymph nodes. • Tenderness of the greater trochanter, as for example in trochanteric bursitis; over the adductor origin in adductor tendinosis; lesser trochanter or a point deep lateral from the femoral artery in the groin as in psoas tendinosis; symphysis pubis with the abdominal insertions. • Nerves. The sciatic nerve midway between the greater trochanter and the ischial tuberosity in the buttock; the femoral nerve laterally from the femoral artery over the joint; the lateral femoral cutaneous nerve medially from the anterior superior iliac spine under the inguinal ligament.
Pas s ive tes t procedures Passive test movements are essential in the examination of movement disorders of the hip. Physiological movements and accessory movements need to be examined on the behaviour and relationship of symptoms (P), resistance (R) and motor responses (‘spasm’ – S). The ndings of the tests will guide the therapist in the selection and application of treatment techniques (see also Chapters 1 and 8)). As many of the passive test procedures may also be used as treatment procedures, frequently the test procedures need to be followed by a reassessment of the main physical parameters found so far. O ften it will be useful to establish a movement diagram of the most comparable active test movements in order to obtain more detailed parameters regarding the behaviour of symptoms and the range and quality of movement by the establishment of the behaviour and the inter-relationship of pain, resistance and motor responses. For example, exion, rotation movements, adduction, abduction
or extension may be examined in more detail and the ndings may be expressed in a movement diagram (see Appendix 1). Physiological movements of the hip may include:
• • • •
Flexion/ adduction and variations Flexion/ abduction and variations Extension/ adduction/ medial rotation Extension/ abduction/ lateral rotation.
Accessory movements may be performed in various positions of the joint and may encompass:
• Posteroanterior movement (on femur, on • • • • • • •
greater trochanter) Anteroposterior movement (on femur, on greater trochanter) Transverse lateral movement (on femur) Transverse medial movement Longitudinal distal movement (parallel to femur shaft) Longitudinal proximal movement (parallel to femur shaft) Medial rotation Lateral rotation movement, including inclination.
Test procedures under compression may need to be added to the test movements if no symptoms have been reproduced, particularly in those cases where an intra-articular movement disorder is suspected. N eurodynamic testing may be included in this section of passive test procedures. A selection of passive examination techniques are described in detail as follows:
• Flexion/ adduction, including differentiation procedures • Accessory movements and test procedures under compression.
Fle xion/a d d uc tion • Direction: Movement of the hip into the arc of exion/ adduction at various points from 80 to 140° of exion. • Symbol: F/ Ad. • Patient starting position: Supine, lying near the right-hand edge of the couch with the hip exed to 90° and the knee comfortably exed. • Therapist starting position: Standing by the patient’s right thigh facing across the patient’s body. 4 11
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Localization o orces (position o therapist’s hands) • Fingers of both hands are interlocked and lightly cupped over the top of the patient’s exed knee (if the patient has a very painful knee the therapist can support under the knee with one hand to bring the leg out of the painful knee exion position) (Fig. 7.30). • The therapist’s right knee is placed on the couch, level with the patient’s knee to maintain balance. • The left thigh is pressed rmly against the edge of the couch at the level of the patient’s hip to give added control to the pelvis movement and to prevent the therapist’s body weight falling fully against the patient’s right thigh.
Application o orces by therapist (method) • The patient’s hip is fully adducted until the right ileum begins to lift from the couch. • The therapist leans against the lateral surface of the patient’s femur so that the therapist’s chin and hands are close together. • The hip is adducted further using small oscillatory movements. Release the movement and ex the hip a further few degrees so that the adduction can be repeated at a different point of hip exion until the whole range (80–140°) has been assessed (Fig. 7.31). • First series: the patient’s hip is adducted until the therapist feels a rst increase in resistance (‘R1’). Then a second series of oscillatory F/ Ad movements is performed over the whole range and the therapist examines the behaviour of
Fig ure 7.30 • Flexion/adduction. 4 12
140° F (towards ipsilateral shoulder) c. 125° F (towards chin)
c. 110° F (towards opposite shoulder) c. 95° F (towards opposite waist) 80° F (towards opposite iliac crest)
Fig ure 7.31 • Flexion/adduction – direction of examination movements.
resistance and the possible behaviour of pain until the limit of the range.
Variations o F/Ad as an examination technique Pr ogression o exa mina tion If F/ Ad is thought to be normal, medial or lateral, rotation and/ or compression through the shaft of the femur or through the neck of the femur should be added as a grade IV− to IV+ in several positions before judgeing the movement as normal or ideal (Figs 7.32 and 7.33).
Fig ure 7.32 • Flexion/adduction with compression through the shaft of the femur (longitudinal cephalad movement).
P h ys ic a l e xa m in a tio n
A
B
Fig ure 7.34 • Diagrammatic representation of: A hip exion/adduction; B hip adduction.
Fig ure 7.33 • Flexion/adduction with compression through the neck of the femur (transverse medial movement, inclined cephalad).
Different combinations are possible, for example, in MR: do F/ Ad; in compression through femur shaft do F/ Ad, etc. To nd the position of painful limitation the hip can be moved in adduction, through the arc of exion/ adduction from 80 to 140° to the point where the patient’s knee is pointing towards the left shoulder from a starting position of the hip in less than 90° of exion. A constant pressure is maintained through the knee along the shaft of the femur in both the exion and adduction directions while at the same time moving the patient’s thigh through a further 60–70° of exion. The femur should lie midway between medial and lateral rotation. If movement is normal or ideal, the knee will follow an arc of a circle (Fig. 7.34A); any small abnormality will be felt as a bump on the smooth arc of the circle (Fig. 7.34B).This point may also be painful. The movement should always be compared with that of the normal hip. Adduct the hip further so that the right ilium lifts off the table. Increase the hip adduction by applying pressure through the patient’s knee downwards in line with the shaft of the femur, thereby pushing the patient’s right ilium down onto the couch again. If the shaft of the femur has been retained in its relationship to the vertical, the pelvis will have adducted under the femur at the hip. This method drives the head of the femur posteriorly in the acetabulum.
This technique can produce groin pain in the normal hip. H owever, if a patient’s main problem is groin pain, the pain will be reproduced earlier in the range when compared with the normal hip.
D i erentia tion tests Flexion/ adduction may be considered as a dominant test and treatment technique of the hip joint; however, other movement components may also be responsible for impairments of the test. While maintaining the leg in the pain-provoking position or slightly short of the painful position, various differentiation tests may be performed to determine the possible contribution of other movement components to the painful movement.
• Neurodynamic system: add knee extension and • • •
•
dorsi exion of the foot; may add neck exion (Fig. 7.35). Lumbar spine: add rotation towards or away from the hip; alternative: patient may put an arm under the waist to prevent further exion. Sacroiliac joint: tilting pelvis posteriorly or anteriorly; alternative: may add lateral traction to the ilium. While tilting the ilium posteriorly the sacroiliac joint increases the movement, while the stress in the hip joint is slightly decreased. If symptoms increase, a sacroiliac movement disorder may be responsible; if symptoms decrease, the hip may be suspected. (N ote: If symptoms increase, the lumbar spine may be differentiated by repeating the same manoeuvre but the patient extends the lower lumbar spine by putting an arm under the spine.) While tilting anteriorly the opposite may occur. H ip joint: add accessory movements. 4 13
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an essential role in the treatment of degenerative osteoarthritis. Figure 7.37 gives some indication of the progression of impairments as they may happen in some pathologies or if maintenance of joint mobility is being neglected.
Acces s ory movements For convenience most of these tests are described as treatment techniques later in the text.
Sp e c i c te s ts for re s tric te d glid ing move me nts In the presence of limited angular or physiological movement where joint blocking (restriction of coupled accessory or gliding movement) is suspected, special tests may be carried out. As joint blocking occurs in association with a faulty axis of rotation it may be related to problems of excessive gliding movements but in the opposite gliding direction. Fig ure 7.35 • Hip joint: exion/adduction with straight leg raise (SLR).
Re s tric te d p os te rior glid ing (Fig. 7.38) • Indication: G ross restriction of physiological hip
Us e s of e xion/a d d uc tion a nd its va ria tions F/ Ad is probably the most useful technique for both examination and treatment. It is as important to the hip as the quadrant is to the shoulder. F/ Ad may be considered as one of the ‘functional corners’ as described in Chapter 1. The curve of F/ Ad may easily be recognized in the circumduction movement as described by Kapandji (1988) (Fig. 7.36). Full mobility of this functional corner permits rotation movements of the trunk while walking and running and is essential in many hip functions such as moving the body or trunk in sitting, putting on socks and so forth. When all other movements are pain free this movement can be painful and restricted. The test manoeuvre may detect minimal impairments such as local pain and little change in resistance and joint mobility. As described earlier, it is essential to treat impairments leading to degenerative changes in a phase as early as possible. H ence the examination and treatment using F/ Ad may play 4 14
• •
• •
exion normally takes place with approximately 90° exion (Note: exion is coupled with posterior gliding movement which due to the curve of the acetabular joint surface also translates further into a slight lateral glide). This may be a feature of the medial migratory OA presentation (see‘ the section on treatment later in this chapter). Test in exion: right hip (modi ed from Sahrmann,2002). Patient position: Supine, with the patient’s hands supporting under the ilium proximally or alternatively a wedge may be placed here. The knees are extended. Therapist position: Standing on the test side. The patient performs an active SLR without hip rotation to the point of restriction. The therapist supports the leg in this position, asks the patient to relax and then moves the leg approximately 10° away from the limit. After applying an anteroposterior pressure on the femoral head using the lateral border of her left hand adjacent to and parallel to the inguinal crease, the therapist again lifts the leg further into SLR.
P h ys ic a l e xa m in a tio n
160
P
C F1 F2 O
E
I
Eq
Ab MR LR
HM L
Ad
Fig ure 7.36 • Circumduction of the hip. Reproduced with permission from Kapandji (1988).
A
B
C
D
Fig ure 7.37 • Changes in F/Ad.
• Dysfunction:
Fig ure 7.38 • Restricted posterior gliding dysfunction. Movement adapted from Sahrmann (2002).
1. If the hip moves remarkably further into exion then the SLR restriction may be due to blocked posterior accessory movement due to overactivity in posterior joint muscles or inhibition of the anterior local stabilizer. 2. If the hip does not move further into exion, or the SLR is even more blocked, then the SLR restriction may be due to blocked posterior accessory movement due to passive tissue restriction, i.e. shortening in posterior joint muscles or capsule. As con rmation, the test (Addison 2004) for excessive anterior gliding in prone may be carried out this time with the 4 15
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ball of each of the therapist’s thumbs under the anterior superior iliac spines and the ngers palpating the femoral head anteriorly. (The therapist’s thumbs rest in front of the second metacarpal). If the femoral head feels prominent on the affected side in relation to the anterior superior iliac spine but does not move further forward during active hip extension, the head may be xed in anterior glide.
Te s t in e xion/a d d uc tion: right hip (Ad d is on 2004) Use the test position described below for excessive posterior gliding dysfunction (see Fig. 7.41) looking for restricted rather than excessive movement. This is de ned at the end of the test.
Fig ure 7.39 • Excessive anterior gliding dysfunction. Movement adapted from Sahrmann (2002).
• Therapist position: The therapist stands on the
Re s tric te d a nte rior glid ing • Indication: Marked restriction of physiological hip extension. (Note: extension is coupled with anterior gliding movements.) • This test for anterior accessory gliding motion may be performed as it is described in the treatment section below comparing left/ right for restriction of movement.
Sta b ility te s ts
Clinical tip: The local s tabilizers (s hort deep one-joint mus cles often ins erting into the joint caps ule) have been s hown to s tabilize individual joints without inhibiting or res tricting angular or phys iological movement in that joint (Panjabi 1992). A mus cle s uch as ps oas will help tighten the hip caps ule preventing exces s ive acces s ory movement while nevertheles s allowing exion or extens ion movements to take place. This centring effect ens ures that the fulcrum of motion lies within the joint. In the pres ence of inhibited s egmental s tabilizers and overactive or s hortened global mobilizers (e.g. tens or fas cia lata, rectus femoris ) this fulcrum will migrate allowing the joint to lever or glide forward.
• • • • •
opposite side leaning across the pelvis to x its position. A wedge may be placed under the anterior superior iliac spine on the test side to provide further stability. The ngers and thumb of the therapist’s right hand grasp the trochanter anteriorly and posteriorly. The patient lifts the extended leg 10°–15° without hip rotation. G ood function: The position of the trochanter remains constant. Dysfunction: The trochanter moves towards the plinth: anterior gliding dysfunction. Adaptation: Instead of extending the hip the patient need only ex the knee. Test variation: See Fig. 7.40.
Exc e s s ive p os te rior glid ing d ys func tion (Fig. 7.41) • Indications: See Table 7.8. • Test: For right hip (Addison 2004). • Patient position: Supine in 80° hip exion, the knee relaxed. • Therapist position: The therapist stands facing the opposite hip with the femur held against her trunk. The middle nger of her right hand
Exc e s s ive a nte rior glid ing d ys func tion (Sa hrma nn 2002) (Fig. 7.39) • Indications: See Table 7.8. • Patient position: Prone lying. 4 16
Fig ure 7.40 • Test variation palpating the femoral head.
Tre a tm e n t
A
B
Fig ure 7.41 • A Excessive posterior gliding dysfunction. B Model of excessive posterior gliding dysfunction.
•
•
•
•
palpates the the ischial tuberosity with the base of the right hand lying against the lateral side of the greater trochanter. Using a trunk movement the therapist adducts the hip to the point where the right anterior superior iliac spine is about to move. The therapist then performs a passive longitudinal cranial movement in the direction of the femoral shaft at the same time palpating movement of the greater trochanter in relation to the tuberosity. G ood function: The trochanter moves minimally posteriorly until it engages the acetabular joint surface (a relatively hard end-feel) and then slightly laterally where a normal end-feel is palpated. The lateral movement range should be compared with the opposite side. Dysfunction: The lateral movement of the trochanter is excessive in comparison with the opposite side and the end-feel is abnormal. N ote: This test may be used to examine restriction of posterior gliding movement which may initially have been caused by excessive anterior gliding: on the above test the trochanter moves minimally posteriorly until it engages the acetabular joint surface but no further lateral movement takes place and the end-feel is hard. If hip exion is tested it will also be restricted.
Exc e s s ive la te ra l glid ing d ys func tion • Indications: Pain in side lying with the affected side above, particularly if adduction appears excessive; pain in side lying with the affected side below, particularly if the body habitually lies in a rolled-forward position on this side; pain in standing when ‘hanging’ sideways on the affected hip; prominence of the trochanter on this side; inability to sit cross-legged in the lotus position due to a lack of abduction. This may be a feature of the ‘up and out’ migratory OA presentation. • Test: This test for lateral gliding may be performed as described below in the section on passive mobilizing techniques with the additional incorporation of a left/ right comparison.
Tre atme nt Passive mobilizing and active stabilizing techniques are described below.
Pas s ive mobilizing techniques : acces s ory movements La te ra l move me nt (Figs 7.42, 7.43) • Direction: Movement of the head of the femur in a lateral direction in relation to the acetabulum. 4 17
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Localization o orces (position o therapist’s hands) In side lying • Both hands grasp around the patient’s thigh anteriorly and posteriorly as near to the hip as possible. • The ngers of both hands spread around the inner thigh. • The thumbs of both hands spread around the outer thigh.
Fig ure 7.42 • Lateral movement, grades I and II.
• Symbol: • Patient starting position:
○ in side lying (grades I and II): side lying with
pillows placed between the legs for comfort, legs exed for comfort ○ in supine (grades III and IV): supine, lying with the hip exed to the chosen angle and the knee exed comfortably. • Therapist starting position:
○ in side lying: standing behind the patient ○
facing in line with the line of the femoral shaft in supine: standing alongside the patient, level with the hip, facing across the patient’s body.
In supine • The sternum is pressed against the patient’s knee. • The ngers of both hands interlock and hold round the medial surface of the patient’s thigh as near to the hip joint as is practicable. • The arms and chest stabilize the patient’s lower leg.
Application o orces by therapist (method) In side lying • The very gentle oscillatory lateral movement is produced by the therapist’s body movement through the whole of the palmar surfaces of all the ngers against the inner thigh.
In supine • In this starting position the oscillatory lateral movement of the head of the femur in the acetabulum is produced by the therapist moving the femur laterally while ensuring that the angle of Ab/ Ad does not alter. • This may require considerable movement of the patient’s knee position to avoid the tendency of the patient’s pelvis to roll as the therapist’s hands help to pull the head of the femur laterally. • The patient’s whole limb and the therapist’s hands, arms and thorax should move as one solid entity while the therapist rocks back and forth (grades III and IV especially).
Variations in the application o orces • The same movement can be performed with
Fig ure 7.43 • Lateral movement grades III and IV. 4 18
the hip in any degree of exion or extension and in different angles of abduction and adduction or in varying degrees of rotation. • While producing lateral movement of the hip the therapist may also:
Tre a tm e n t
1. Stabilize the patient’s knee, preventing its lateral movement so that the lateral movement of the hip is combined with a small degree of hip horizontal adduction 2. Carry the knee in parallel with the hip so that a small degree of hip horizontal abduction takes place.
• To increase range using accessory lateral movement at the limit of physiological range (e.g. medial rotation), the therapist can rst of all ex and rotate the hip to its limit; the therapist’s trunk must then be turned to face the patient’s feet while simultaneously producing the lateral movement. In this way, the patient’s whole limb and the therapist’s hands, arms and trunk move as an entity as the required movement is produced by the rocking action of the therapist’s body. • Straps and belts can be used but the therapist may then lose the feedback information on the quality and range of movement available. H owever, a small therapist treating a large patient may require a strong grade IV1 movement in treatment and is therefore justi ed in using such equipment.
Uses • Recovery of range following fracture of the femur or acetabular region. • Capsular tightness or a medially migrated OA hip. with associated loss of exion. • Painful hip conditions or stiff ranges of movement.
Longitud ina l move me nt c a ud a d (Figs 7.44-7.47) • Direction: Movement of the head of the femur in a longitudinal caudad direction in relation to the acetabulum. • Symbol: • Patient starting position: ○ in supine: lying in the middle of the couch, knee slightly exed, heel on the couch ○ in side lying: lying on the left side with pillows between the legs and the hips positioned in mid- exion/ extension, knees comfortably exed ○ in exion: supine, lying with hip exed to 90° or at the limit, knee fully exed.
• Therapist starting position:
○ in supine: standing level with the patient’s
○
○
right knee facing the patient’s head. The therapist’s right knee is placed on the couch supporting under the patient’s slightly exed hip and knee (Fig. 7.45) in side lying: if thumb contact is to be used the therapist stands behind the patient in line with the femur (Fig. 7.44). If the patient’s femur is to be used as leverage the therapist stands behind the patient and leans across the patient’s body so that the pelvis is cradled in the therapist’s left axilla (Fig. 7.46) in exion: standing by the patient’s side facing the patient’s head (Fig. 7.47).
Localization o orces (position o therapist’s hands) In supine • The therapist kneels (right shin on couch). • The right thigh is placed diagonally under the patient’s knee. • Alternatively, the therapist sits on the edge of the couch. • The right leg, fully exed at the knee and laterally rotated at the hip, placed under the patient’s thigh. • Both hands encircle the distal end of the patient’s femur.
In side lying • Both thumbs are placed on the greater trochanter. • Fingers spread widely to help stabilize the thumbs. • Forearms are directed in line with patient’s femur. • If the leg is to be used as leverage, both hands grasp the lower end of the patient’s femur just proximal to the femoral condyles.
In f exion • The ngers of both hands interlock and grasp around the anterior surface of the patient’s thigh as far proximal as is practicable. • The head and shoulders cradle the patient’s knee to stabilize the hip and knee angle. 4 19
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Longitudinal movement caudad
Fig ure 7.44 • Longitudinal movement caudad, grades I and II.
Fig ure 7.45 • Longitudinal movement caudad.
Fig ure 7.46 • Longitudinal movement caudad, alternative method, grades I and II.
420
Fig ure 7.47 • Longitudinal movement caudad in exion, grades III and IV.
Tre a tm e n t
Application o orces by therapist (method) In supine • The oscillatory longitudinal movement is produced by pulling gently on the patient’s femur. • This technique can be assisted by a rolling or sliding movement of the therapist’s supporting thigh under the patient’s leg in the direction of the treatment movement. • The technique should be performed gently with no discomfort for very painful disorders and in varying degrees of exion.
In side lying • If the therapist’s thumbs are to be used, •
• •
•
• •
extremely gentle and comfortable longitudinal movement can be produced. The therapist’s thumbs should not be the prime movers but should act as spring-like contact points, feeling the movement that is taking place. The therapist’s arms and body gently rock back and forth in line with the patient’s femur. If the patient’s femur is to be used the therapist’s left axilla must stabilize the patient’s pelvis to prevent it moving while the technique is being performed. In this way the longitudinal movement is produced as an oscillatory movement through the therapist’s hands which clasp the distal end of the patient’s femur. The movement should be produced by the therapist’s arms. The therapist’s body cannot be used because loss of control of the patient’s pelvis would occur.
combined in exion/ adduction or exion/ abduction positions (group 2).
Uses • Very soothing for painful hip disorders. • Superior migrating OA and capsular tightness.
P os te roa nte rior a nd a nte rop os te rior move me nts (Figs 7.48, 7.49) • Direction: Movement of the head of femur in posteroanterior and anteroposterior directions in relation to the acetabulum. • Symbols: , • Patient starting position: Side lying with the upper leg supported by pillows in the neutral position or at the limit of the stiff range (if leg is used a leverage: supine or side lying). • Therapist starting position: PA – standing behind the patient; AP – standing in front of the patient (if leg is used as leverage: next to patient).
Localization o orces (position o therapist’s hands) Poster oa nter ior • The pads of both thumbs, pointing towards each other are placed against the posterior
In f exion • The therapist’s grasp of the patient’s leg is such that the therapist’s feet can rock back and forth as the leg rocks in the same direction.
Variations in the application o orces • The longitudinal movement performed in exion can be adapted so that it can be performed in any chosen angle of abduction or adduction. • In exion, more exion can be added as the longitudinal movement is produced (group 2) or exion can be reduced a few degrees during the technique (group 3b). Flexion may also be
Fig ure 7.48 • Posteroanterior movement. 421
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Variations in the application o orces • The thumbs can be used to produce the PA and
Fig ure 7.49 • Anteroposterior movement.
surface of the greater trochanter (grades I and II). • The ngers are spread around the thumbs which should be in direct bone-on-bone contact with the trochanter. • Alternatively, the heel of the hand is placed against the posterior surface of the greater trochanter (grades III and IV).
Anter oposter ior • The pads of both thumbs pointing towards each other are placed against the anterior surface of the greater trochanter (grades I and II). • The ngers are spread around the thumbs which should be in direct bone-on-bone contact with the trochanter. • Alternatively, the heel of the hand can be placed against the anterior surface of the greater trochanter (grades III and IV).
Application o orces by therapist (method): PA and AP • For grades I and II soft, gentle, small oscillatory movements are produced by the therapist’s body and arms through the thumbs stabilized against the trochanter. • The movement should not be produced by the thumb intrinsic muscles as the movement needs to be both discomfort- and pain-free. • For grades III and IV the heel of the hand, via the body and arms, produces the stretching movement while the other hand needs to stabilize the patient’s pelvis via the anterior superior iliac crest. 422
AP movements in the same way as described above but with the patient lying supine. • With the patient lying prone the heel of one hand can be used to produce a PA movement on the posterior surface of the greater trochanter while the therapist’s other hand is used to take the patient’s hip and leg into more extension. • The point of contact around the greater trochanter can be changed to explore a variety of inclinations to the technique. • Supine: both hands around the leg – one palm of the hand just below the ischial tubercle, the other hand just below the joint in the inguinal fold. Produce the movement with gentle movements of the trunk.
Uses • Very little PA and AP movement of the head of the femur takes place in the acetabulum. H owever, these movements may be useful as a treatment for very painful hip disorders (grades I and II). • Can be used as an accessory movement at the limit of stiff physiological exion/ extension range (grades III and IV). • May be a technique to consider in disorders such as subtrochanteric bursitis or piriformis syndrome. • Treatment techniques under compression
Along the fe mora l line (longitud ina l move me nt c e p ha la d ) (Fig. 7.50) • Direction: Compression of the head of the femur into the acetabulum along the line of the femur (longitudinal cephalad movement). • Symbol: femur, or ceph. • Patient starting position: Supine, lying on the couch. • Therapist starting position: Standing beyond the patient’s slightly exed right knee facing the patient’s head.
Localization o orces (position o therapist’s hands) • The therapist’s thigh supports under the patient’s slightly exed knee.
Tre a tm e n t
• Stronger techniques will produce associated pelvic movement. • The technique, generally, should be performed into slight pain or discomfort or short of the onset of severe irritable pain.
Variations in the application o orces • This compression technique can be performed
A
with other movements such as rotation or exion and extension. • While compression is maintained, other movements can be added. • While compression is maintained along the shaft of the femur through the knee, the hip can be medially or laterally rotated via the patient’s lower leg and foot.
Uses • Mild aching in the hip with weight bearing. • To reproduce and treat joint surface pain.
Comp re s s ion me d ia lly (with tra ns ve rs e me d ia l move me nts ) (Fig. 7.51) • Direction: Compression of the head of the
B
Fig ure 7.50 • Rotation added to longitudinal cephalad compression: A medial rotation; B lateral rotation.
• The right hand cups over the patient’s tibial tuberosity. • The left hand adds to the support under the patient’s knee.
Application o orces by therapist (method) • The oscillatory movement of pushing of the head of the femur into the acetabulum is performed by the therapist’s right hand thrusting against the front of the patient’s tibia in the line of the femur. • The return oscillation is guided by the therapist’s left hand against the back of the patient’s knee.
femur into the acetabulum in a medial direction. • Symbol: neck, or medial. • Patient starting position: Lying on the pain-free side (in this case the left side). • Therapist starting position: Leaning across the patient from in front.
Localization o orces (position o therapist’s hands) • The heel of the right hand is cupped over the patient’s left greater trochanter. • The right shoulder is positioned directly over the right hand. • The left hand and forearm hold round and support the patient’s lower leg medially, making maximum contact.
Application o orces by therapist (method) • The therapist produces a sustained squeezing together of the head of the femur medially into the laterally facing articular surface of the acetabulum. 423
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Application of forces by therapis t (method)
A
B
C
D
E
F
Fig ure 7.51 • Compression medially: A in neutral; B producing extension; C producing exion; D producing abduction; E producing lateral rotation; F producing medial rotation.
• Via the therapist’s right shoulder the head of the femur is then squashed towards the oor in an oscillatory overpressure fashion. • The time needed to apply the pressure and reproduce the patient’s symptoms should be 424
related to the time the patient is able to lie on the painful hip before becoming aware of the symptoms (Fig. 7.51A). • While the pressure is sustained the therapist’s body and right hand pivot around the patient’s
Tre a tm e n t
right hip to produce extension (Fig. 7.51B) and exion (Fig. 7.51C). • The therapist’s trunk is side exed to produce abduction at the patient’s hip (Fig. 7.51D). • For lateral rotation, the therapist’s body is curved forwards over the patient’s right hip resulting in the patient’s left foot being lowered towards the oor while the knee is retained in mid exion and extension, abduction and adduction (Fig. 7.51E). • For medial rotation the reverse action of the therapist’s body will produce medial rotation (Fig. 7.51F).
F/Ad as a treatment technique
A
B
Uses • Chronic hip symptoms which make it uncomfortable for the patient to lie on the painful hip. • OA hip which is painful when the patient’s lies on the affected side. • Loss of ability to sit in the lotus or tailor position or to sit with the foot on the opposite knee.
C
D
E
Fig ure 7.52 • Diagrammatic representations of different hip exion/adduction movements.
F/Ad as a treatment technique
Uses
• F/ Ad as a treatment technique can be carried
• Probably the most useful hip technique for both
out in grades II, III and IV (Fig. 7.52).
Gra d e IV Small oscillations at end of range (grade IV) can be directed against the painful limit as treatment in one of three ways: 1. With a F/ Ad movement directed towards the limitation (single headed arrow) (Fig. 7.52C). 2. By moving through an arc of F/ Ad backwards and forwards over the limitation (double-headed arrow) (‘rolling over’) (Fig. 7.52D). 3. Using small oscillatory movements in an arc, back and forth at either side of the limitation (two double-headed arrows) (‘scooping’) (Fig. 7.52E). If the patient has a very painful knee the therapist can support under the knee with one hand to bring it out of the painful knee exion position.
examination and treatment. As important to the hip as the quadrant is to the shoulder. • When all other movements are pain free, this movement can be painful and restricted when the hip is a source of minor symptoms. • H ip exion and adduction are not described separately as F/ Ad serves the purpose of both. • The technique can be used in clinical groups 3b and 2 and group 4 in combination with medial rotation and compression.
Gra d e s II a nd III (Figs 7.53, 7.54) • Patient starting position: Supine, lying with the hip exed accordingly and the knee exed to approximately 90°. • Therapist starting position:
○ grade II: standing at the level of the patient’s right thigh facing the left shoulder. The therapist’s body is positioned as a stop at the 425
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○ the left hand supports the patient’s knee ○ the right hand supports the patient’s foot so as to maintain the mid-rotation position.
Application o orces by therapist (method) G r a d e II • The large amplitude oscillatory movement
Fig ure 7.53 • Flexion/adduction grade III.
○
lateral extent of the F/ Ad movement (this would be further away for a grade III) grade III: standing at the level of the patient’s right thigh facing the left shoulder. The right knee rests on the couch and the left thigh leans against the edge of the couch.
Localization o orces (position o therapist’s hands) G r a d e II • The left hand holds the patient’s right knee. • The right hand holds the patient’s foot. • The body position is adjusted to face the appropriate direction of F/ Ad.
G r a d e III • Both hands rst hold the patient’s exed knee in order to ex and adduct the hip to the limit of the range at the chosen point in the arc. • The grip is then altered so that:
should not reach the limit of the range and is performed back and forth by the therapist’s arms. • The depth to which the movement reaches is determined by the onset and increase of pain, and is performed short of any resistance. • The return movement and therefore the arc of oscillation is determined by the therapist’s body position which acts as a stop.
G r a d e III • The large amplitude oscillatory movement of approximately 30° (to 90°) is directed towards the limit in a straight line. The amplitude of the patient’s foot must equal that of the knee. • The therapist’s body is positioned to form a stop at the outer limit of the movement. • The therapist swings the patient’s knee towards the limit of F/ Ad to where the patient’s pelvis starts to lift off the couch and into a degree of resistance. • The discipline is to perform the technique smoothly and without any hip rotation.
Uses • Clinical group 3a (grade II), 3b (grade III). • Resolving hip pain or to help restore range of movement after injury. • To help settle an exacerbation of osteoarthritis. • As a technique to ease off treatment soreness.
Other pas s ive treatment techniques Me d ia l rota tion (Figs 7.55-7.60)
Fig ure 7.54 • Flexion/adduction grade II. 426
Medial rotation is frequently restricted and painful, and may be more restricted in hip exion than in extension or vice versa, and such variations should be sought during examination. As a treatment technique medial rotation can be performed in grades I, II, III and IV and may be varied in different positions.
Tre a tm e n t
Medial rotation
Fig ure 7.56 • Medial rotation, alternative method for grades I and II.
Fig ure 7.55 • Medial rotation, grades I and II.
Fig ure 7.57 • Medial rotation in extension supine for grades III and IV.
Fig ure 7.58 • Medial rotation in extension prone for grades III and IV.
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Medial rotation—cont’d
Fig ure 7.60 • Medial rotation in exion, grades III and IV.
Fig ure 7.59 • Medial rotation, grade IV, left ilium pushed back towards the couch.
• Direction: Medial rotation of the hip joint in various physiological positions. • Symbol: • Patient starting position: ○ in supine (grades I and II): supine, lying near to the right edge of the couch (Fig. 7.55) ○ in side lying (grades I and II): left side lying with a pillow between the legs to support the hip in the neutral pain-free position (Fig. 7.56) ○ in extension supine (grades III and IV): supine, lying near the right side of the couch at a slight angle to bring the patient’s left 428
foot near the edge of the couch and so that the right knee is free of the edge (Fig. 7.57) ○ in extension prone (grades III and IV): prone, lying with the knee exed to a right angle (Figs 7.58 and 7.59) ○ in exion (grades III and IV): supine, lying near to the right edge of the couch with the hip and knee exed to right angles (Fig. 7.60). • Therapist starting position:
○ in supine: standing at the level of the
patient’s knee facing across the patient’s body. Right knee placed on the couch with
Tre a tm e n t
○ ○ ○ ○
the thigh carefully positioned so as to support the patient’s thigh and calf for comfort and to allow the patient’s hip and knee to ex a few degrees so that the patient’s heel rests on the couch (Fig. 7.55) in side lying: leaning across the patient’s hip from behind (Fig. 7.56) in extension supine: kneeling by the patient’s right thigh facing the left knee (Fig. 7.57) in extension prone: standing by the patient’s right knee facing the hip (Figs 7.58 and 7.59) in exion: standing by the patient’s right hip facing the left knee (Fig. 7.60).
Localization o orces (position o therapist’s hands) In supine • Both hands grasp around the patient’s right knee. In side lying • The left axilla is positioned so as to support the patient’s hip. • The left hand holds round and under the patient’s knee to stabilize it and to feel for the hip rotation. • The right hand holds under the patient’s right ankle and foot to stabilize it.
In extension supine • The left forearm supports under the patient’s knee. • The right hand holds the patient’s right foot. • The left forearm stabilizes the patient’s knee.
In extension pr one • The left knee rests on the couch. • The left thigh forms a comfortable stop to the patient’s leg at the limit of hip medial rotation. • The right hand holds the patient’s heel. • The left hand holds the patient’s forefoot. • The left leg is adjusted to the height required to prevent further medial rotation.
In f exion • The left hand supports the patient’s knee. • The right hand supports the patient’s heel.
Application o orces by therapist (method) In supine (gr a des I a nd II) • Small or large oscillatory movements of the patient’s femur are produced by light pressure against the lateral surface of the patient’s knee.
In side lying (gr a d es I a nd II) • The therapist holds around the patient’s knee using the left hand. • A constant position of Ab and Ad and exion/ extension must be maintained. • Small or large oscillatory movements are produced by raising and lowering the patient’s foot using the right hand. • No pain or discomfort should be felt in the hip.
In extension supine (gr a d es III a nd IV) • The therapist medially rotates the patient’s hip by raising the heel laterally. • G rade IV movements are produced by moving the patient’s foot laterally to the limit of the range while maintaining an equal and opposite counterpressure against the lateral side of the patient’s knee using the left forearm. • O scillatory movements of medial rotation are controlled by the therapist’s left hand; the pressure with the left arm should be quite rm. • G rade III large amplitude movements are produced by lowering the patient’s right foot, which releases the pressure against the therapist’s left forearm. While lowering the foot, the therapist must take care to maintain the patient’s thigh in a constant position so that only medial rotation is produced.
In extension pr one (gr a d es III a nd IV) • Medial rotation is produced by the drawing of the patient’s foot towards the therapist until it reaches the therapist’s thigh as a stop. The patient’s foot and leg are then oscillated back and forth by the therapist’s arms. • The use of inversion of the patient’s foot, while it is being drawn towards the therapist, makes for a better action. • The therapist may need to have the right hand positioned against the lateral side of the patient’s thigh during medial rotation to prevent hip abduction.
In f exion (gr a des III a nd IV) • The therapist medially rotates the patient’s hip and at the same time prevents the hip abducting by using the left hand to apply pressure against the lateral side of the patient’s knee. 429
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• The therapist’s right hand then moves the patient’s foot in an arc around the patient’s knee.
Variations in the application o orces In extension pr one • As with nearly all passive movement treatment techniques the movement of the joint can be produced from either of the bones forming the joint. • In the case of medial rotation of the hip (grade IV) the same starting position as for medial rotation in extension prone (Figs 7.58 and 7.59 can be adopted but with suf cient medial rotation to allow the patient’s ilium to be raised a few centimetres from the couch. • By stabilizing the patient’s lower leg the therapist can produce medial rotation of the patient’s right hip by oscillatory pressure on the patient’s left buttock, moving the left ilium back towards the couch (Fig. 7.59).
Uses • Very painful disorders of the hip (clinical groups 1 and 3a).
• Stiff hips which require mobilization to improve • •
• •
range (clinical groups 2 and 3b). Frequently restricted movement in many hip disorders. If used in conjunction with an anteroposterior accessory glide it may be of help for the blocking which takes place during high kicking. (martial arts and ballet) O steoarthritic hips. As a shaft rotation technique to incorporate roll and slide of the femoral head in the acetabulum, including a small degree of Ab and Ad due to the roll of the leg.
La te ra l rota tion (Figs 7.61, 7.62) • Direction: Lateral rotation of the head of the femur in the acetabulum. • Symbol: • Patient starting position: ○ in exion supine: supine, lying with the hip and knee exed to 90° ○ in extension prone: prone, lying with the knee exed to 90°.
Fig ure 7.62 • Lateral rotation in extension, prone.
Fig ure 7.61 • Lateral rotation in 90° exion, supine.
430
Tre a tm e n t
• Therapist starting position:
○ in exion supine: standing by the patient’s ○
right hip facing the left knee in extension prone: standing by the patient’s left knee facing the right hip. The therapist’s right knee is placed on the couch using the thigh positioned so as to provide a stop at the limit of lateral rotation of the patient’s hip.
Localization o orces (position o therapist’s hands) In f exion supine • The left hand holds the patient’s exed knee and stabilizes it. • The right hand holds the patient’s foot. • The therapist’s body is adjusted to face the patient’s left shoulder when the hip is at the limit of lateral rotation.
In extension pr one • The right hand holds the patient’s forefoot. • The left hand holds the patient’s heel.
Application o orces by therapist (method) In f exion supine (gr a d es III a nd IV) • The oscillatory movements are produced by moving the patient’s foot back and forth in an arc around the knee. • The therapist’s left hand and trunk maintain the position of the knee as the centre of the arc of movement. • If the hip is exed a few degrees during the medial rotation phase of the oscillation and then extended back through those few degrees during the lateral rotation phase, the technique is sometimes easier to perform. This action lessens the amount of work required by the right hand.
Variations in the application o orces • In side lying: lateral rotation in side lying can be performed in a similar way to that described for medial rotation (Fig. 7.56) except that the patient’s foot is pushed into the pillow to perform oscillatory grade I and II lateral rotation.
Uses • Used less often than medial rotation and exion/ adduction. • Usually best performed in exion. • May be useful as a pain-modulating technique, such as medial rotation in supine and in side lying. • Best used to treat stiffness in exion or in extension prone.
Ab d uc tion (Fig. 7.63) • Direction: Movement of the hip into abduction (either in exion or extension). • Symbols: Ab, Ab/ E, Ab/ F. • Patient starting position: ○ in exion: supine, lying with the hip exed to 20° for very painful disorders or into more degrees of exion (all positions possible) ○ in extension: supine, lying with the hip and knee in extension and the legs abducted comfortably.
In extension pr one • H ip lateral rotation is produced by lowering the foot towards the stop until the limit of the range is reached. • The oscillatory lateral rotation is then performed by a back and forth action of the therapist’s arms. • The movement can be enhanced by icking the foot into eversion as the hip is laterally rotated.
Fig ure 7.63 • Abduction in extension. 431
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• Therapist starting position:
○ in exion: standing by the patient’s exed ○
hip and knee, level with the knee and close to the patient’s leg to form a stop in extension: standing by the patient’s right lower leg facing the hip, right shin placed on the couch, sit back on the right heel.
Localization o orces (position o therapist’s hands) In f exion • The left hand is placed over the femur to support the patient’s knee. • The right hand is placed over the patient’s tibia. • The patient’s leg is abducted to the point in range intended for treatment.
In extension (Fig. 7.63) • The left hand supports under the patient’s knee. • The right hand supports under the patient’s ankle.
Application o orces by therapist (method) In f exion • Small and large amplitude oscillatory movements are produced by the action of the hands on the patient’s knee. • Watch that the movement is not taken beyond the point where the patient’s pelvis starts to move.
In extension • The oscillatory movements usually do not exceed 10–15° and are produced by the therapist’s arms and hands with the patient’s leg just free of the couch. • The therapist’s right leg acts as a stop at the limit of the abduction range required.
Variations in the application o orces • In extension the range can be increased by placing a towel under the patient’s buttock.
Uses • To increase the range of hip abduction limited by pain or stiffness. • OA hip where abduction has become stiff and painful. Particularly for the superiorly migrating OA hips. H ere abduction may be combined 432
with a longitudinal caudally and medially directed accessory glide. • G roin strain where abduction is the painful hip movement.
Exte ns ion • Direction: Extension of the hip. • Symbol: E. • Patient starting position: Supine near the edge of the couch with the hip and knee in extension. • Therapist starting position: Standing by the patient’s side beyond the knee facing the left knee.
Localization o orces (position o therapist’s hands) • The left hand holds laterally around and under the patient’s knee. • The right hand holds under the patient’s heel from the medial side.
Application o orces by therapist (method) • The therapist’s left hand raises the patient’s knee 15–20 cm from the couch. • The right hand keeps the patient’s heel off the couch and moves it towards the patient’s buttock 7–10 cm. • The therapist then carries the patient’s heel away from the buttock and allows the knee to lower to the limit of extension. • If the hip disorder is very painful the therapist’s thigh can support under the patient’s knee to provide a stop.
Variations in the application o orces • A towel under the patient’s buttock can increase the range of the limit of extension. • The patient’s left hip and knee may be exed for comfort.
Uses • Where patients are having dif culty with hip extension as in walking. • Particularly limited in OA hips.
Exte ns ion/a b d uc tion • Direction: Movement of the hip into extension/ abduction. • Symbol: E/ Ab.
Ac tive te c h n iq u e s
• Patient starting position: Supine, lying with the hip and knee in extension. • Therapist starting position: Standing by the patient beyond the knee and facing the patient’s opposite shoulder.
Localization o orces (position o therapist’s hands) • The left hand supports under the patient’s knee. • The right hand supports under the patient’s ankle.
Application o orces by therapist (method) • The therapist rocks backwards to lower the patient’s leg into E/ Ab. • A grade II amplitude of 20–40° is performed using the therapist’s arms and body, with the hip positioned in mid rotation.
Uses • When hip extension and abduction are limited by pain or stiffness.
Ac tive te c hnique s Active correction of pos ture and movement patterns This will be particularly important for patients with minor instabilities or hypermobilities. H owever, patients with a stiff or blocked joint who compensate with excessive lumbar spine and/ or knee involvement will also bene t from active correction (incorporating more hip movement) once hip range of movement has been regained (see the clinical tips in Box 7.5).
Box 7.5 Clinical tips: active correction of posture and movement patterns A
Hyp e rmob ile d is ord e rs
•
Correction of the s ymptomatic pos ition •
•
•
•
• • •
Alignment s hould be corrected in a pain-free pos ition if pos s ible. Initially, temporary external s upport may be us ed (pelvic belt) or the pos ition may be adapted to decreas e pain (high s itting ins tead of deep s itting; s ide lying rolled s lightly forward ins tead of s traight) Alignment s hould be corrected tonically: • Us ing minimal effort • Experienced as eas y and relaxing • Maintained for 10 s econds with 10 repetitions • Without fatigue, tremor or cramping Vis ual feedback may be us ed initially to check alignment (us e of a mirror, reference points on the body) Facilitatory techniques incorporating tactile and proprioceptive input may be incorporated at rs t: Tape (for example, the McConnell hip tape), us e of braces (s uch as the SERF belt) to control exces s ive medial rotation or a pelvic belt to provide compres s ion), manual s timulation, light s tretch and the us e of balance reactions Focus initially on s ingle components . Later multiple components may be corrected s imultaneous ly Frequent repetition throughout the day Encouragement and pos itive feedback will help
The level of exercis e s hould not exceed the patient’s capabilities
Correction of the s ymptomatic activity •
•
•
Movements s hould be performed without pain, us ing tonic recruitment, feedback and facilitatory techniques as above Movements s hould be performed extremely s lowly initially with 15–20 repetitions ; with the s peed progres s ively increas ing Dis s ociation exercis es (Sahrmann 2002) may be incorporated initially: the hypermobile hip is maintained in its neutral pos ition while the res tricted proximal (lumbar s pine) or dis tal joints (knee) are actively moved, for example, during a golf s wing to the left, right hip lateral rotation may be exces s ive and painful while the lumbar s pine and knee s how limited rotation. The patient may be given two different dis s ociation exercis es : 1. While maintaining the hip and lower limb in neutral rotation (no movement from the pelvis to the foot), the patient rotates the lumbar s pine and trunk to the left 2. While maintaining the hip and trunk in neutral rotation, the knee is laterally rotated by rotating the thigh, pelvis and trunk as a xed unit with res pect to the tibia
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Box 7.5—cont’d •
•
B
Whole body movement can now be incorporated. For the above example this may be achieved by rotating rs t the trunk, then the knee without any hip involvement; progres s ing to adding limited hip rotation The s ymptomatic activity may then be s imulated without exces s ive hip rotation and nally the golf s wing may be practis ed with golf club and ball
Minor ins ta b ility d is ord e rs
s tabilizers to additionally correct exces s ive gliding movement
Correction of the s ymptomatic activity •
Once the s egmental s tabilizer can be cognitively contracted, follow the s teps des cribed for the hypermobilities above while maintaining the contraction
Correction of the s ymptomatic pos ition •
In correct global alignment as des cribed above, add in tonic contraction of the s egmental
The s egmental s tabilizers (adapted from Comerford & Mottram 2001, Gibbons 2001) P s oa s (Fig. 7.64) • Patient starting position: As for the right hip, supine, near the edge of the plinth. • Therapist starting position: Standing facing the patient. ○ the therapist’s right hand grasps around the posterior surface of the knee holding the medial and lateral femoral condyles with the thumb and ngers. ○ the left hand xes the ilium. • Procedure: The therapist performs very gentle hip distraction and compression passively. The
patient is then instructed to help by slowly and lightly pulling the head of the hip into the socket with as little effort as possible. At the same time the therapist maintains a gentle distraction force. The patient should hold the contraction for 30 seconds without pain, fatigue, tremor or cramping. During this time the therapist tests passive rotation of the hip to ensure that it is relatively free and that the pulling-in movement is not being performed by the larger global muscles. There should be no visible super cial muscle activity. To ensure that the contraction has not been slowly lost during the 30-second hold, the therapist compares the amount of distraction present during and upon release of the contraction. • Training:
○ the patient practices 10 repetitions of the
○
10-second hold. A minimum of twice daily is recommended H owever, the exercise can be performed as often as possible. practising in different positions (sitting, standing, side lying, etc.) helps in integrating control into daily activities.
Ge me lli a nd ob tura torii (Fig. 7.65) • Patient position: In prone, knees apart and in
Fig ure 7.64 • Recruitment of psoas. 434
90° exion, heels together. • Therapist position: Standing at the side of the affected hip with one nger placed between the patient’s heels; the other hand palpating the gemelli and obturatorii muscles just below the piriformis and above the quadratus femoris
Ac tive te c h n iq u e s
Fig ure 7.65 • Recruitment of the gemelli and obturatorii.
• Procedure:
○ the patient is given one of the following
instructions: . ‘gently pull both hips into their sockets’, ‘make the width of the hips smaller’ or apply gentle slow pressure of the heels against the nger’. ○ the therapist feels for light tonic pressure between the heels and for the contraction of the gemelli and obturatorii. The other buttock muscles should be palpated to check that they are relatively inactive. • Training:
○
○
the patient practices 10 repetitions of the 10-second hold. A minimum of twice daily is recommended. H owever, the exercise can be performed as often as possible. practising in different positions (sitting, standing, side lying, etc.) helps in integrating control into daily activities.
The global s tabilizers • Tonically recruiting and shortening the global stabilizers in a particular position does not necessary mean that this recruitment will automatically take place during performance of the symptomatic activity. The brain is concerned with goal-orientated activities and recruiting movement patterns. Therefore, these isolated muscle exercises are no replacement for training to correct the symptomatic position and the symptomatic activity. Nevertheless they are of help. • For ideal tonic function the aim will be to achieve the perfect test result described for
each global stabilizer in the assessment. The test positions are in non-weight-bearing positions where tonic recruitment is more dif cult to achieve than in weight-bearing positions due to the reduced proprioceptive input. Therefore, it may be more dif cult for a patient to stabilize well in lying than in standing. H ence in cases of stability dysfunction, side lying or turning in bed may be a more painful activity than standing or walking. Patients with trochanteric bursitis or iliotibial tractitis, for example, often have dif culty lying on their good side with the affected side hanging in adduction. If the posterior gluteus medius could be recruited and shortened the patient would automatically choose a more rolled-forward position as the resting position and hence relieve compressive or stretching forces on the involved tissue.
• If training in the test position is too dif cult the muscle contraction may be facilitated at rst through weight bearing. If the patient cannot do the test with weight bearing, then contact through the sole of the foot will also increase input: an exercise for contracting the gluteus maximus in supine may be facilitated by lightly pressing the foot against the wall or by oor contact over the side of the bed.
• If training in the test position is too dif cult the test position may be adapted by shortening the lever, for example, by bending the knee in the test position. (The deep gluteus maximus would be the exception here as bending the knee could tighten an already shortened rectus femoris or tensor fascia lata making the contraction more dif cult).
• Training in a weight-bearing position (sitting or standing) is often more ‘user-friendly’ and will ensure that the patient practises more often, for example, while waiting in a queue. Recruitment of the gluteal muscles may be obtained simply by standing on one leg with the pelvis level and the hip in neutral exion/ extension and neutral abduction/ adduction. As a progression the exercise may be performed in increasing external rotation requiring more shortening of the muscle.
• Training should be pain-free if possible: This may require the patient to work at lower levels of activity than the muscle is capable of. For example, a trochanteric bursitis resulting from excessive frictioning of the iliotibial tract over 435
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the greater trochanter (due to an inhibited/ lengthened posterior gluteus medius and an overactive/ shortened tensor fascia lata), may be exacerbated by strong contractions of the posterior gluteus medius in side lying, convincing the patient that exercise is of no use. O n the other hand, gentle tonic contractions in standing or sitting may condition soft tissues to accept greater forces over time. • Tonic contraction of the muscle should ideally be maintained in the shortened position for 10 seconds. O n returning to the starting position the muscle should be relaxed and the exercise immediately repeated. A total of 10 repetitions is ideal. H owever, if the patient is incapable of holding the contraction without fatigue or phasic activity (tremor, cramping), the exercise should be held for shorter intervals with fewer repetitions but performed more often throughout the day. A minimum performance of 10-second holds with 10 repetitions twice a day is the goal. • Patience compliance is essential: if the level of exercise is too dif cult or the patient feels he will never achieve accurate performance, he may well forget or nd that he is too busy to exercise. Insistence on perfection is often therefore detrimental and the patient should be given much positive feedback in order to approach exercise in a relaxed and positive frame of mind.
The global mobilizers • By performing lengthening exercises actively an antagonistic or more proximal global stabilizer may be used to simultaneously inhibit the global mobilizer to be lengthened. The holding positions described below should be maintained for 30 seconds with three repetitions.
Ha ms trings • Starting position: The end test position described in the assessment (see page 406). • Procedure: The patient may be asked to passively hold the knee in the maximum degree of extension achieved where the lumbar spine begins to lose its neutral position and then actively realign the lumbar spine using the super cial multi dus and iliacus to inhibit the hamstrings. 436
Glute us ma ximus (s up e r c ia l b re s ) • Starting position: In a sitting position with the thighs supported, the lumbar spine in neutral and the hips in as maximal adduction to the point where the lumbar spine starts to lose its neutral position. • Procedure: Actively reposition the lumbar spine in neutral and hold. (Activity in the super cial multi dus and iliacus should inhibit gluteus maximus).
Te ns or fa s c ia la ta It is possible to lengthen the tensor using an adaptation of the Thomas’ test. H owever, this is not recommended as the exercise is not user-friendly and may subject the joint to excessive anterior gliding stress causing it in time to become unstable. This may be a concern if there is any intra-articular pathology leading to local stabilizer (psoas) inhibition and resultant gliding rather than the aimed-for lengthening of the mobilizer (tensor fascia lata and rectus femoris). • In standing against the wall: This test position is also carries the risk of producing excessive anterior gliding in time. H owever, it is ‘userfriendly’ and may therefore be used in the absence of intra-articular pathology (e.g. for iliotibial tractis or gluteal bursitis). ○ starting position: Standing with the back against the wall, knees straight; feet hipwidth apart and 5–7 cm from the wall. The patient carefully abducts the hips to nd the point where the lumbar spine has dif culty maintaining contact with the wall. ○ procedure: The patient further actively exes the lumbar spine using the oblique abdominals and deep gluteus maximus to inhibit the tensor. • Using the modi ed O ber’s test position: This test position is safe but not ‘user-friendly’. • Starting position: Side lying with the test side above. The patient’s waist is held pressed against the plinth (in lumbar lateral exion).The right and left trochanters lie vertically in the same plane; the lower leg bent; the test hip is in neutral exion/ extension and full lateral rotation and is supported on towells at the point where the trunk lateral exion position or the hip rotation position would be dif cult to maintain if the hip was adducted further.
Ac tive te c h n iq u e s
• Procedure: The patient holds the waist against the plinth to maintain trunk lateral exion using the oblique abdominals/ super cial multi dus or externally rotates the hip using the posterior gluteus medius/ quadratus femoris to inhibit the tensor.
• Procedure: The patient is asked to actively hip-hitch without losing hip position. • O n release the therapist attempts to externally rotate the hip to a new starting position.
The long a d d uc tors
Re c tus fe moris
• Starting position: Supine, the lumbar spine in
• Starting position: Single-leg stance on the non-test side; lumbar spine and test hip in neutral position. The knee is exed to resistance while maintaining lumbar and hip positions. • Procedure: The patient may be asked to passively hold the knee (with a belt, for example) in the maximum degree of exion achieved without losing hip position and then actively contract the gluteal muscles to inhibit the rectus femoris.
P iriformis • Starting position: Supine, with the hip exed to approximately 85°, the knee in 90° exion, the hip adducted to resistance and then externally rotated to the point of resistance. (The patient will need the assistance of a family member to hold this position).
neutral, the non-test leg extended on the plinth. O n the test side the hip is exed to approximately 45°, the knee is in 90° exion with the foot resting on the plinth adjacent to the opposite knee. The patient allows the knee to fall outwards as far as possible without movement of the anterior superior iliac spines or foot position. • Procedure: At the point where the pelvis begins to rotate, the patient is asked to realign the pelvis and hold. Clinical pro les are presented for the following common disorders related to hip movement dysfunctions:
• • • • •
O steoarthritis (Table 7.9) Athletic groin pain (Table 7.10) Torn acetabular labrum (Table 7.11) Trochanteric bursitis (Table 7.12) Meralgia paraesthetica (Table 7.13).
Table 7.9 Clinical pro le: osteoarthritis
Examination
Clinical evidence/‘brick wall’ thinking
Kind of disorder
Pain and restricted mobility in various daily life activities
Body chart features
Symptoms in the groin area, radiating to the medial side of thigh down to the knee. Also symptoms in the right buttock and lower back area, which do not seem related to the symptoms in the thigh area. Symptoms in the groin area are ‘pinching’, with a pulling sensation in the leg
Activity limitations/24hour behaviour of symptoms
May include activities such as driving, gardening and walking. Stiffness, especially in the morning when rising from bed and getting up after prolonged periods or sitting or squatting. Easing factors: rotation movements of the leg. Patients may indicate that the disorder needs a balance between rest and activity (but not too much of both)
Present/past history
Gradual onset of symptoms in a prolonged history of constant awareness of discomfort studded with exacerbations. Some patients indicate that the pain and disability increased over time and they may not be symptom free any more. With those patients, symptoms may have progressed from occurring during weight-bearing activities towards symptoms at rest (especially at night). However, other patients may say that they have improved over the years, as, for example, after retirement from sedentary work, more activities (e.g. walking) are being performed
437
Table 7.9 Clinical pro le: osteoarthritis—cont’d
Examination
Clinical evidence/‘brick wall’ thinking
Special questions Source/mechanisms of symptom production
Pain originating from the subchondral bone exposed by full thickness articular defects. Furthermore, capsular and ligamentous structures may cause nociceptive activity. Neurogenic mechanisms and intraosseous vascular mechanisms may also play a role in symptom production
Cause of the source Contributing factors
Habitual gait patterns, lack of muscular control, loss of joint mobility and reduced aerobic condition as neuromusculoskeletal contributing factors
Observations
No local changes (e.g. bony or synovial thickening) visible. Postural changes, especially pelvic position leading to hip exion. Muscular wasting possible: gluteal muscles, quadriceps. Underactivity of abdominal muscles
Functional demonstration of active movments
Painful leg movements (e.g. putting on socks, squatting, crossing legs active movements in sitting). Many movements, especially F, Ad, MR and E may be restricted and pain provoking. Crepitus is rare. Gait analysis is essential. If symptoms are dif cult to reproduce, crossing the legs may be particularly indicative. Tests in weight-bearing, especially Ad, MR and E may provoke symptoms with ‘through-range’ ndings
If necessary tests
Symptoms may increase when the tests movements are performed under compression
Other structures in plan
Essential: screening of lumbar spine, sacroiliac joint. Further tests: muscular recruitment and muscle length
Isometric/muscle length tests
Mostly inconclusive with regard to symptom reproduction
Neurological examination Neurodynamic testing
Neurodynamic testing needs to be performed as a routine procedure; however, it may not be involved in the movement disorder
Palpation ndings Passive/accessory movement
Pain and stiffness through range. In particular, F/Ad, MR and E may be physiologically combined restricted and painful. Accessory movements will react accordingly movements with changes in through-range resistance and pain. The friction-free feel of passive movement may be lost with the joint surfaces compressed together
Mobilization/manipulation Accessory movements at end-of-range and in-range positions, if techniques preferred and suf cient range of motion is present: F/Ad. Large amplitude treatments should be used in variation with end-of-range amplitudes. Minor symptoms may also respond to passive mobilization with the addition of intermittent joint compression Other management strategies
NSAIDs and pain-relieving medication may be necessary. Consider joint replacement in severe cases. Restoration of muscular control by coordination, aerobic conditioning, automobilizations of joints and muscle stretching, pain-coping strategies. Advice to take regular, moderate activity (e.g. walking, biking, swimming)
Prognosis/natural history
Osteoarthritis can be classi ed as a mechanical, degenerative, traumatic or systemic disease. In the mechanical type, if pain and dysfunction are due to a mechanical disorder within the joint and if passive mobilization and exercises can alleviate the mechanical factors, the patient’s symptoms should resolve accordingly. The traumatic and degenerative types may have some residual impairments of restricted mobility, but with appropriate management and advice patients can remain symptom free for long periods. The disease type relates to the systemic type of osteoarthritis which generally follows a progressive natural history. In such instances mobilization can be a means of alleviating symptoms but total rheumatological management of this type of osteoarthritis is essential
Evidence base
See Chapter 8 for evidence of passive movement and articular cartilage repair; van Baar et al. (1998), Hoeksma (2004).
Ac tive te c h n iq u e s
Table 7.10 Clinical pro le: athletic groin pain (with emphasis on tendinitis)
Examination
Clinical evidence/‘brick wall’ thinking
Kind of disorder
Symptoms in groin and pubic area related to certain sports activities
Body chart features
Local symptoms in groin and pubic area
Activity limitations/24-hour behaviour of symptoms
In all sports where sudden rotation and acceleration are required (e.g. rugby, soccer). Symptoms may occur with activities such as kicking a ball, twisting movements of the leg. Occurs in long distance running, usually during speed or hill work. If of muscular origin, symptoms may occur during contraction or stretching of muscles (e.g. adductor tendinitis: squeezing knees together; iliopsoas tendinitis: lifting leg in sitting)
Present/past history
Acute: related to certain sports activities and frequently contracting or stretching affected muscle groups (e.g. adductor tendinitis: for example, in kicking a ball at the same moment as the opposition/through a block tackle)
Special questions Source/mechanisms of possible symptom production
The following structures/pathological processes need to be considered as a source of symptoms: Referred symptoms: lumbar spine, thoracic spine, sacroiliac joint; neurodynamic system Local, other than hip joint: Adductor tendinopathy, adductor longus muscle Iliopsoas tendinopathy Rectus femoris tendinopathy Rectus abdominis tendinopathy Osteitis pubis Pelvic stress fractures Pubic instability (especially if adductor tendinitis seems to occur in conjunction with rectus abdominis tendinitis) Nerve entrapment: ilioinguinal nerve, obturator nerve Hernia inguinalis Genitourinary pathology (e.g. prostatitis)
Cause of the source Contributing factors
Repetitive overuse activity
Observations
Swelling or prominence at insertions
Functional demonstration of active movements
Twisting movements, kicking ball. In cases of tendinitis, minor restrictions of hip movements
If necessary tests Other structures in plan
Screening of lumbar spine, sacroiliac joints, thoracic spine
Isometric/muscle length tests
Isometric testing may provoke the symptoms. Exact localization of the source may be possible if careful palpation is carried out during the isometric testing
Neurological examination Neurodynamic testing
In cases of entrapment neuropathy, modi ed femoral nerve tests may reproduce symptoms
Palpation ndings
In cases of tendinitis: tenderness over insertions, muscle
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Table 7.10 Clinical pro le: athletic groin pain (with emphasis on tendinitis)—cont’d
Examination
Clinical evidence/‘brick wall’ thinking
Passive movement, accessory/ physiological combined movements
In cases of tendinitis: often unrevealing
Mobilization/manipulation techniques preferred
Soft tissue techniques, modalities
Other management strategies
In acute phases: rest, ice, compression for about 48 hours. Gently increase stretching and contraction within pain-free limits. Muscular recruitment, instruction regarding warming up/cooling down and self-management (pain- coping strategies, e.g. gentle stretching, soft tissue treatment) essential
Prognosis/natural history
Depends on the identi cation of the inter-relationship between the actual components and mechanisms. In cases of localized tendinitis with a short and clear history – good prognosis
Evidence base
’There is no consensus on diagnosis, pathophysiology or management’(Orchard et al. 2000)
Table 7.11 Clinical pro le: torn acetabular labrum
Examination
Clinical evidence/‘brick wall’ thinking
Kind of disorder
Pain in groin area with twisting movements while weight bearing
Body chart features
Sharp ‘catching’ pain in the groin which may radiate into the thigh. Usually at the front of the joint. Over time pain may become diffuse and dif cult to localize
Activity limitations/24-hour
Often provoked by pivoting movements. Initially lasts only for a few behaviour-of-symptoms minutes; may become more frequent and longer lasting. Associated click may be present. Frequently during soccer or other sporting activities
Present/past history
Symptoms may be acute but more commonly occur over a number of months. Related to sports activities such as soccer; can also occur by overuse or by acute trauma from a violent blow to the hip
Special questions Source/mechanisms of symptom production
Acetabular labrum
Cause of the source Contributing factors
Overuse with repeated twisting movements
Observations Functional demonstration of active movements
Twisting movements in weight-bearing positions may provoke the pain of active movements and/or click. Symptoms may be provoked on axial compression. Pinching sensation during hip exion, adduction, medial rotation and combinations
If necessary tests Other structures in plan
Differentiate from other movement components which may refer symptomsinto the same area
Isometric/muscle length tests
Frequently inconclusive
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Ac tive te c h n iq u e s
Table 7.11 Clinical pro le: torn acetabular labrum—cont’d
Examination
Clinical evidence/‘brick wall’ thinking
Neurological examination Neurodynamic testing Palpation ndings Passive movement, accessory/physiological
Pain and apprehension on impingement provocation tests involving exion, adduction and internal rotation (anterosuperior tears); hyperextension, combined movements abduction and external rotation (posteroinferior tears). Moving the hip from full exion, external rotation and abduction to extension with internal rotation and adduction – pain reproduction and/or clicking may be an indication of a labrum tear
Mobilization/manipulation
Depending on the pain, gentle passive movements with accessory movements short of the painful position may in uence the pain
Other management strategies
Depending on other impairments and habitual movement patterns found in physical examination
Prognosis/natural history
In minor cases restoration of function may be expected. However, in some persistent cases arthroscopy should be considered. Postoperative management: restoration of full range of motion, muscular control and guidance to normal level of activities and sports
Evidence base
Fitzgerald (1995)
Table 7.12 Clinical pro le: trochanteric bursitis
Examination
Clinical evidence/ ‘brick wall’ thinking
Kind of disorder
Pain localized over local area of greater trochanter
Body chart features
Usually local pain, may radiate down lateral or posterolateral aspect of the thigh
Activity limitations/24-hour
Symptoms with climbing stairs, sleeping on affected side, crossing legs. Pain behaviour of symptoms particularly in lying on the side, walking for longer periods of time
Present/past history
Gradual onset of symptoms; tends to run a protracted course that is punctuated by exacerbations and remissions, often related to activity
Special questions Source/mechanisms of symptom production
May be local structure. May be referred symptoms from lower lumbar spine, sacroiliac joint, hip
Cause of the source Contributing factors
This overuse lesion tends to occur in two groups of patients: those involved in activities (e.g. extensive running) or in middle-aged (usually female) often overweight patients with associated degenerative changes in the lower lumbar spine
Observations
Muscle wasting; tight iliotibial band
Functional demonstration of active movements
Crossing legs, lying on affected side may reproduce symptoms. Adduction, active movements extension may reproduce symptoms. Local symptoms with lumbar active tests
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Table 7.12 Clinical pro le: trochanteric bursitis—cont’d
Examination
Clinical evidence/ ‘brick wall’ thinking
If necessary tests Other structures in plan
Screening of lumbar spine, sacroiliac joint, neurodynamic structures essential
Isometric/muscle length tests
Hip abductors may reproduce the symptoms partially
Neurological examination Neurodynamic testing
May be symptomatic if lumbar spine is involved
Palpation ndings
Increased temperature in local area possible
Passive movement, accessory/physiological combined movements
Hip movements frequently concomitantly painful, e.g. F/Ad; in particular L4–5 accessory movements may partially provoke the symptoms
Mobilization/manipulation techniques preferred
Treatment of concomitant lumbar and hip joint signs is essential
Other management
Soft tissue techniques and application; treat muscle imbalance, especially of gluteal muscles, quadriceps and abdominal muscles, stretching of tensor fasciae latae and iliotibial band. Instruct patients in self-management strategies. Sports people: advice on warming up/cooling down programmes
Prognosis/natural history
Depending on the inter-relationship of contributing components to the movement disorder
Table 7.13 Clinical pro le: meralgia paraesthetica (lateral femoral cutaneous nerve entrapment)
Examination
Clinical evidence/‘brick wall’ thinking
Kind of disorder
Burning pain at lateral side of thigh
Body chart features
Quality of symptoms: burning, stinging, numbness, paresthesia down the proximal lateral aspect of the thigh. Other symptoms may be present in knee area, buttock and lower back
Activity limitations/24-hour
Symptoms with longer periods of sitting with involved leg under body, prolonged behaviour of symptoms sitting, squatting, increased walking, standing
Present/past history
Gradual, spontaneous onset of symptoms associated with, for example, obesity, wide belts, tight jeans, pregnancy, diabetes mellitus and prior inguinal surgery. At times may be the result of trauma
Special questions Source/mechanisms of
Symptoms typical of peripheral neurogenic mechanisms. May be associated with symptom production movement disorders of lumbar spine, hip
Cause of the source Contributing factors Observations
442
Overweight, clothing
Ac tive te c h n iq u e s
Table 7.13 Clinical pro le: meralgia paraesthetica (lateral femoral cutaneous nerve entrapment)—cont’d
Examination
Clinical evidence/‘brick wall’ thinking
Functional demonstration of active movements
Frequently inconclusive, as symptoms may develop after remaining for long periods in the same position. Lumbar spine, hip movements need to be routinely examined
If necessary tests Other structures in plan Isometric/muscle length tests Neurological examination
Motor function fully intact. Hyperaesthesia over lateral thigh, increased light touch sensation, increased pin-prick sensation
Neurodynamic testing
Slump test in side lying (including hip extension and adduction) may provoke the symptoms. Variation of the test: patient may lie on the affected side (Butler 2000)
Palpation ndings
Deep palpation just below the anterior superior iliac crest may reproduce the symptoms
Passive movement, accessory/ physiological combined movements
Hip movements frequently concomitantly painful or restricted (e.g. F/Ad)
Mobilization/manipulation
Treatment of concomitant lumbar and hip joint signs is essential. Neurodynamic techniques preferred treatment respecting the symptoms
Other management strategies
In ltration of the nerve at it course at the inguinal ligament. Recommendation on clothing, weight loss. Surgery is rarely considered
Prognosis/natural history
Some authors state that in many cases a spontaneous resolution may occur within two years. However, the results may be dependent on the inter-relationship of all other contributing components in the disorder
Evidence base
See for example Butler (2000)
Cas e s tudy 7.1 A movement disorder related to degenerative osteoarthritis in combination with a minor lumbar movement disorder Mr B is a 67-year-old retired cons truction worker whos e hobbies include gardening, biking (2–3× weekly for 2–3 hours ), hiking in mountains (at leas t 1×/week), s kiing in winter.
Kind of d is ord e r Symptoms in leg, es pecially during walking, getting up from s itting, gardening. Activities in daily life: ‘annoying’, but carries on with them as us ual.
Bod y c ha rt As pointed out in Figure 7.66, the s ymptoms in the buttock and the groin area do not appear to have a relations hip.
Ac tivity limita tions /24-hour b e ha viour of s ymp toms *
Gardening (es p. pulling weeds ), after c. 2 h Gets up and ‘s hakes ’ leg a bit; after c. 15’ 100% * Squatting (e.g. when playing on oor with grandchild), after 5’ ‘annoying’ Changes pos ition on oor quickly * Putting on s ocks (in s itting) – cros s es ri. leg over le. leg, ‘hard to do’, little bit immediately, once leg s traight again * Currently only after driving a car for 2–3 h; s itting in a cinema after 2–3 h
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Cas e s tudy 7.1—cont’d
2 Pulls Y, D
3
1
Pulls Y, D
Pinches Y, D 1a Pulls Y, D
1 1a Together 2
3 Together
1
2 3 Separate
Fig ure 7.66 • Body chart of Mr B.
Gets up and walks around: s ettles quickly Night: Morning at getting out of bed s tiff* , es p. in walking – s ettles after 30’; then Day: as above; p.m./a.m.: no difference; in general: needs movement more than res ting
Sp e c ia l q ue s tions GH: ; Medic. none; no his tory of accidents or illnes s es ; X-ray le. and ri. hips : degenerative changes in both hips (no difference left/right).
P re s e nt/p a s t his tory Short-term (pres ent) his tory is illus trated in Figure 7.67.
P la nning of p hys ic a l e xa mina tion
Pas t his tory
Hypothes es
• •
•
a Never had , nor res tricted movements . s ince c. 20 years . 5 years ago: ++ went to Dr and PT for 1s t time; pas s ive mobilizations and s elf-managements . Good effects ; did not continue with exercis es . Better now than 4–5 years ago: attributes this to increas ed level of activity (is retired): regular biking, hiking, and s kiing.
444
•
•
Symptom mechanis ms : nociceptive mechanis ms (s timulus –res pons e related s ymptoms ). Tis s ue mechanis ms : degenerative changes with OA, however s ymptoms developed only after fall on right hip. Main s ource of s ymptoms : hip ; Lx , neural s ys tem ; (later: s creen SIJ (s acroiliac joint)).
Ac tive te c h n iq u e s
Cas e s tudy 7.1—cont’d Short term Hx
Since when
Details on onset
Course over time
Now: onset
started ca. 3 months ago
Noticed it 1st in the morning – stiff 1 ; Lx 2 3 were unchanged; Did a lot of skiing in that period; fell 2–3x; felt a bit stiff in legs at D1 but DLA incl. skiing were normal
Gradually 1 1a ( 2 3 remained isq) – Noticed difficulties with squat, putting on socks and shoes, gardening GP PT
Now: DLA not limited; however 1 1a isq since ca. 2 months
1
Fig ure 7.67 • Short-term history.
Procedures of examination •
•
No s peci c CI/precautions (not s evere/irritable; no s peci c ‘nature’ factors ) → routine tes ting pos s ible: until L (res p. P). Tes t hip and Lx movements ; after active tes ting decide: Continuation P/E hip OR continuation P/E Lx.
De c is io n: Screening neurodynamics ; then continue P/E hip.
Ne urod yna mic te s ts
P hys ic a l e xa mina tion (D1) • • •
• •
PP Ins pection: nothing particular; ant. tilt pelvis : correction Functional demons tration and differentiation: *Putting on s ocks (s itting; R leg cros s ed over L) Diff: Lx, SI s tres s : ISQ NS (Neck exion): pulls in buttock *Hip (ri. leg) *Squat: , deviates in Ab/Lat Rot, act EOR a Corr. deviation: , [+][+] Gait: forwards , backwards , s mall s teps , large s teps : *Cros s ing le. leg over ri. leg: , Active tes ts Active tes ts on 1-leg: F, E, Ab, Ad, MR, LR all , ] Lx: *F 10 cm, act 1 NF E 20°, L1–5 s tiff, loc. P Lx-area *LF le: , act EOR; ri: , Rot le 5 ri , Lx Q le , (loc. P); ri , (loc. P) Hip supine Hip prone F 120°, IV− E 10° (ri. 20°), IV11 In 90° F: MR , IV− MR , ; LR , In 90° F: LR Ab 40°, Ad 25°,
Pas s ive tes ts hip F/Ad Ri. hip: all directions , (Fig. 7.68) Le. hip: res tricted, (Fig. 7.69) LE. hip: in F/Ad (pos . c) – before P 1 (Fig. 7.70): do P/E acces s ory movements : * femur, lat, lat/caud, femur, troch, troch, caud: ,
C/O: ‘lighter’, ‘more comfortable to move’ P/E: F 125°, IV + ☺ In 90° F: MR range , IV−☺ Squat: deviation Lx: F, LF le.: ISQ Warned patient: P m ay be m ore localized and and intense – exp. S hould observe AND com pare:*stiffness a.m .; *squat; *sitting on oor; *gardening;
Plan (D4, Rx 2) • • • •
Cons ideration of hypothes es : movement dys function of hip , with res tricted mobility Plan s es s ion 2: s creen Lx – effects of PAIVMs on hip function and Lx function Decide: continue Rx Lx? OR continue Rx hip? (F/Ad; in EOR F/Ad: acc. mvt; automob. F/Ad) (Screening SIJ : Rx 3)
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Cas e s tudy 7.1—cont’d Passive tests hip F/AD
R2 (IV++)
All directions
P' 1
Fig ure 7.68 • Passive tests: hip exion/adduction.
R1
P1
Fig ure 7.70 • Left hip: in exion/adduction. d c
D4, Rx 2 • b
a A
R2 (IV++)
•
P' 1 •
B
R2 (IV++)
C/O: Felt lighter in area for c. 4 h, then ISQ Gardening, s quat: ISQ Putting on s ocks : s eemed les s s tiff Morning: s eemed les s s tiff – s till c. 30 mins Lx: no change (did not bother at all; did not s it for longer periods ) P/E: *Lx F 5 cm *Lx LF left *Putting on s ocks little (overpres s ure: ) *Squat: little dev in Ab/LR, little *Gait s ideways : ISQ as after Rx 1 *In s upine: hip F 125°, IV− *In s upine, in 90° F: do MR c. 20°, IV− Palpation and P/E PAIVMs T10–L5/S1 (Fig. 7.71):
Temp, s weating, s kin tone, C/O: ISQ bony alignment, mus cle tone: P/E: Lx: F, LF: range , ISQ Inters pin. s pace (ISS) Hip: Squat, putting on L2–5, laminae le. and ri. L2–5: s ocks , gait, F, ‘thick’, ‘full’ T10–L2; MR: ISQ T10–L5; T10–L2 , ; L3–L5; L3–L5 De c is io n: continue Rx hip, as des cribed in plan Rx 2.
Summa ry of re ma ining tre a tme nt s e s s ions •
C
Fig ure 7.69 • Left hip: restricted.
446
The hip was treated and cleared with F/Ad techniques (grades IV, IV+, s lightly before the ons et of pain) as well as with acces s ory movements in EOR pos itions of F/Ad. Thos e acces s ory movements which were impaired in Rx 1 were s elected as treatment intervention.
Ac tive te c h n iq u e s
Cas e s tudy 7.1—cont’d R2 (IV++)
Thes e exercis es were performed 2–3×/day and when s ymptoms were increas ed. • •
P', loc. P
R1
P1
Fig ure 7.71 • Palpation and physical examination PAIVMs, T10–L5/S1. •
Automobilizations for F/Ad were given: • •
F/Ad in s itting. F/Ad in s tanding, with the leg on the s eat of a chair; trunk exion and automobilization with AP pres s ures on the femur.
•
Screening of the s acroiliac joint with provocation tes ts and pas s ive movements : no effect. Although the lumbar s pine was not fully impairment free, it was decided to repeat s ome of the s elf-management s trategies that the patient learned c. 5 years ago. The patient indicated bene cial effects of thes e after longer periods of s itting. In a retros pective as s es s ment in the eighth s es s ion, left s ide exion was s till s lightly res tricted; however, it was s ymptom free with overpres s ure. Lumbar exion was cleared with regard to the s ymptoms . The patient was encouraged as a ‘joint care’ to maintain the lumbar and hip s elf-management s trategies (mainly automobilizations ) after completion of the treatment. To enhance long-term compliance, it was determined collaboratively with the patient where pos s ible dif culties regarding the execution of the exercis es may occur and adaptations to the exercis es were performed (Appendix 2).
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Sahrmann S: Diagnosis and Treatment of M ovement Impairment Syndromes, St Louis, 2002, Mosby. Schenker ML, Martin RL, Weiland DE, et al: Current trends in hip arthroscopy: a review of injury diagnosis, techniques and outcome scoring, C urr O pin O rthop 16:89–94, 2005. Sherry MA, Best TM: A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains, J O rthop Sports Phys Ther 34(3):116–125, 2004. Sims K: Assessment and treatment of hip osteoarthritis, M an Ther 4:136–144, 1999. Sims K: Assessment and treatment of hip osteoarthritis: implications for conservative management. In Beeton KS, editor: M anual Therapy M asterclasses. The Peripheral Joints, 2003, Edinburgh. Churchill Livingstone, pp 35–47. Soames R: Joint M otion. C linical M easurement and Evaluation, Edinburgh, 2003, Churchill Livingstone. Souza RB, Powers CM: Concurrent criterion-related validity and reliability of a clinical test to measure femoral anteversion, J O rthop Sports Phys Ther 39(8): 586–592, 2009. Stokes M, Young A: Investi gations of quadriceps inhibition: implications for clinical practice, Physiotherapy 70(11):425–428, 1984. Tak E, Staats P, Van H espen A, et al: The effects of an exercise program for older adults with osteoarthritis of the hip, J Rheumatol 32(6): 1106–1113, 2005. Tonley J, Yun S, Kochevar R, et al: Treatment of an individual with piriformis syndrome focusing on hip muscle strengthening and movement reeducation: a case report, J O rthop Sports Phys Ther 40(2):103–111, 2010. van Baar M, Dekker J, O ostendorp RA, et al: The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee:
a randomized clinical trial, J Rheumatol 25:2432–2439, 1998. van den Berg F: Angewandte Physiologie: 1. Das Bindegewebe des Bewegungsapparates verstehen und beein ussen, Stuttgart, 1999, G eorg Thieme Verlag. Verrall G M, Slavotinek JP, Fon GT: Incidence of pubic bone marrow oedema in Australian Rules football players: relation to groin pain, Br J Sports M ed 35:28–33, 2001. Verrall G M, Slavotinek JP, Barnes PG , et al: Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to de ned clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria, Scand J M ed Sci Sports 15:36–42, 2005. Verrall G M, Slavotinek JP, Fon GT: O utcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury, Am J Sports M ed 35:467–474, 2007. Wagner T, Behnia N, Ancheta W-KL, et al: Strengthening and neuromuscular reeducation of the gluteus maximus in a tri-athlete with exercise-associated cramping or the hamstrings, J O rthop Sports Phys Ther 40(2):112–119, 2010. Weinstein J: The role of neurogenic and non-neurogenic mediators as they relate to pain and the development of osteoarthritis, Spine 17(10S):S356–S361, 1992. Whittle M: G ait Analysis: An introduction, O xford, 1991, Butterworth-H einemann. Wroblewski B: Pain in osteoarthrosis of the hip, The Practitioner 1315: 140–141, 1978. Zhang W, Moskowitz RW, Nuki G , et al: OARSI recommendations for the management of hip and knee osteoarthritis, O steoarthritis Cartilage 16:e137–e162, 2008.
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Key words Li es tyle changes , os teoarthritis , patello emoral pain, tibial emoral joint, s uperior tibiof bular joint, patella emoral joint
Intro duc tio n Knee pain is one of the most frequent conditions treated by MSK-physiotherapists and is mentioned as one of the most common disorders of noncommunicable diseases. The increased life expectancy recorded in recent decades, together with changes in lifestyle and diet, has led to a rise in the incidence of non-communicable diseases. It has been recognized that musculoskeletal or rheumatic diseases are the major cause of morbidity throughout the world, having a substantial in uence on health and quality of life, and in icting an enormous burden of costs on health services. Within this group 40% of 450
people over the age of 70 suffer from osteoarthritis of the knee, with a substantial number of them having limitations of movement and restrictions in daily life activities (WH O 2003). In addition, lifestyles in the industrialized world have become more sedentary and diet has changed over the decades since the Second World War. The impact of inactivity and diet on health issues is increasingly acknowledged and it has been recognized that regular physical activity is effective in the primary and secondary prevention of several diseases, for example, cardiovascular disease, diabetes, some forms of cancer, hypertension, obesity, depression, osteoarthritis and osteoporosis. Furthermore, there is an indication that musculoskeletal tness is of particular importance to elderly people in maintaining their independence (Warburton et al. 2006). These health effects due to lifestyle choices have been noted not only in the adult population, but also in children. It has been observed that serious health problems are being created by the ongoing decrease in physical activity, both moderate and vigorous, from early childhood onwards. Poor habits as regards regular movement and diet are established early in life and carried into adulthood. Lifestyle choices in childhood may have an impact on the individual’s health for many years to come (Thein-Brody & Thein-Nissenbaum 2007). As it is expected, in the years to come, that the number of individuals suffering from musculoskeletal disorders will increase, the global alliance known as the Bone and Joint Decade 2000–2010 has de ned its goals as to improve the health-related quality of life for people with musculoskeletal conditions
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throughout the world by raising awareness of the suffering and the cost to society associated with these conditions, by empowering patients to participate in decisions concerning their care, by promoting cost-effective prevention and treatment and by advancing the understanding of musculoskeletal conditions and improving prevention and treatment through research (WH O 2003 p. 3). The Bone and Joint Decade has extended its mandate until 2020 with the motto ‘Keep people moving’ (WH O 2010). In this process, physiotherapists play a crucial role in the treatment of pain, impairments and disabilities, but also in the prevention of long-term disabilities and in the guidance of individuals towards a healthy, active lifestyle. H owever, it appears that physiotherapy may still be an underutilized treatment for knee problems in spite of its recommendation as rst-line treatment in many guidelines (Jordan et al. 2004). With regard to the functional capacity of the knee complex, physiotherapists may be confronted with movement dysfunctions of the knee due to disuse, misuse and/ or lack of activity of the structures on the one hand, and to pain and disabilities caused by traumatic incidents on the other. In both cases, the rehabilitative process should ultimately lead to an optimization of physical tness and wellness. Wellness encompasses social, occupational, physical, spiritual, intellectual and emotional components. The physical aspect of wellness is related to the awareness of the need for regular physical activity, healthy diet and nutrition and avoiding habits that are harmful to wellness (Moffat 2007). Fitness encompasses the following components (Moffat 2007): • Aerobic capacity (ability to participate in activity over time using the body’s oxygen uptake, delivery and energy-release mechanisms) • Muscle strength (the ability of muscles to exert or resist a force) • Muscle endurance (the ability of muscles to perform sustained work) • Power (the ability of a muscle to exert high force at high speed) • Balance (the ability to maintain equilibrium when the body is static or moving) • Agility (the ability to perform power movements in opposite directions) • Flexibility (the ability to be stretched, easily bent or pliable).
Applie d the o ry and e vide nc e s uppo rting prac tic e Many movement disorders of the knee may be related to nociceptive processes and concomitant changes in mobility, motor control and aerobic condition. Therefore, in this section a short overview is given of some of the anatomical and mechanical properties of the knee complex, together with a brief outline of some common disorders encountered by physiotherapists in clinical practice. The knee joint, the largest synovial joint in the body, combines considerable mobility and strength with the stability necessary to lock the knee in the upright position. A bicondylar hinge joint, the knee is made up of three functional units: the medial and lateral tibiofemoral compartments and the patellofemoral joint. The superior tibio bular joint is included in the knee complex. It is often overlooked as a source of nociceptive lateral leg and knee pain. It needs to be examined routinely in movement disorders of both the foot and the knee (Corrigan & Maitland 1994).
Anatomy The femoral condyles rest on the tibia and the intercondylar femoral groove is slightly widened to the lateral side. The femoral condyles are convex from anterior to posterior and from side to side. The medial condyle bulges out more than the lateral condyle. The tibial condyles are relatively at with a slight posteroinferior inclination of the condyles. The lateral condyle is smaller and rounded, concave from side to side, but concavo-convex from front to back. The articular surfaces of the tibia are deepened by the lateral and medial menisci (Palastanga et al. 1994). The anatomical shapes allow for a large amount of glide and roll movements on an intra-articular level. The instant centre of rotation of the joint ranges from about 30° to 60° of exion in a normal joint, indicating a large amount of gliding movement. H owever, rotation movements also play an essential role in intra-articular movement behaviour, in particular to allow an optimal stability in extension movements in weight bearing (Kapandji 1987, Nordin & Frankel 2001). 451
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The articular surface of the patella is oval and a vertical ridge divides the joint surface into a smaller medial area and a larger lateral area. In exion the medial side has more contact with the medial condyle. The articular cartilage, having to transmit large stresses, is probably the thickest cartilage of the body (Palastanga et al. 1994).
Stability and mobility Stability (particularly in extension) and mobility are essential for the knee joint to ful l the requirements of a weight-bearing joint. Both functions are secured by the interplay of ligaments, menisci, muscles and complex gliding and rolling movements at the articular surfaces (Palastanga et al. 1994, Nordin & Frankel 2001). Nevertheless, the joint is quite vulnerable to dislocations and strains to the ligaments, muscles and intra-articular structures, including the menisci, as the articular surfaces have a relatively poor degree of interlocking (Palastanga et al. 1994). In locomotion the knee joint plays an important role in shortening and lengthening the leg, and – in conjunction with the ankle – in the propulsion of the body and transmission of forceful stresses including lateral and rotation movements of the joint (Palastanga et al. 1994). Motion occurs simultaneously along three axes, although exion and extension predominate (Nordin & Frankel 2001). H owever, many functional movements and symptom-provoking activities concerning the knee joint need to be considered in the light of combined movements, for example, extension and adduction or abduction combinations, exion and rotation combinations and so on, as these speci c combinations frequently play an essential role in the delivery of successful treatment with passive movement.
Movement patterns , motor control patterns During exion/ extension movements of the knee the patella follows a complex three-dimensional movement pattern, with a large amount of gliding over the femoral condyle in combination with rotation movements and laterally and medially directed movements (Kapandji 1987, Van Eijden 1990). The patella may glide approximately 7 cm in relation to 452
the femoral condyles when the knee moves from full extension to 140° of exion, in which the patella rotates laterally beyond 90° of exion (Nordin & Frankel 2001). Stabilization training should contribute to the healing of supporting tissues, such as ligaments, to strengthen surrounding musculature and to reestablish motor control and appropriate movement patterns of that joint (Magee & Zachazewski 2007). It has been stated that, particularly in the last degrees of extension or rst 20° of exion, a balance in the recruitment patterns of the vastus medialis oblique and lateralis is essential to permit optimum tracking of the patella in the femoral groove (McConnell 1996), in which the vastus medialis oblique should react earlier and faster than the vastus lateralis during the movement (Witvrouw et al. 2004). Larger muscle groups, such as hamstrings, adductors, gastrocnemius and particularly the tensor fascia latae with the iliotibial band contribute to the motor control patterns of the knee. Motor patterns of the knee are in uenced by the alignment of the foot and the trunk-pelvis-hip area, and therefore the patterns of the abductors and lateral rotators of the hip, the muscles stabilizing the pelvis and trunk. and also the intrinsic foot muscles and those muscles controlling pronation of the foot, often need to be incorporated in physical examination procedures of the knee (Sahrmann et al. 2011). The popliteus muscle is active in the monitoring of subtle transverse- and frontal-plane knee joint movements, controlling anterior–posterior lateral meniscus movement and unlocking and internally rotating the knee joint during exion. In standing, the popliteus assists in a three-dimensional dynamic postural stability of the leg and provides for postural equilibrium adjustments. The popliteus muscle acts in synergy with dynamic hip control of the femoral internal rotation and adduction and with subtalar dynamic control of the tibial abduction-external rotation or tibial adduction-internal rotation respectively. The popliteus assists the quadriceps femoris, hamstrings and gastrocnemius in the knee joint stabilization in the sagittal plane (Nyland et al. 2005).
Range o motion The following ranges of motion have been described (Soames 2003):
• Active range of exion to extension: 140° with the hip exed and 120° with the hip extended.
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Passively the range may increase to 160°, allowing the heel to touch the buttock • Medial and lateral rotation are in uenced by the degree of exion of the joint. In extension rotation is minimal. In 90° of exion active medial rotation is 30° and lateral rotation is 45°. Beyond 90° of exion the range of rotation decreases again.
been questioned already some decades ago (Bullough 1984, Dieppe 1994) and it has been recognized that, as well as mechanical factors, chemical, immunological, hormonal and genetic factors may contribute to the condition (Martin 1994). The American College of Rheumatology has de ned the following criteria for the diagnosis of knee osteoarthritis (H ochberg et al. 1995):
• Knee pain and radiographic osteophytes and at
Nerve s upply The knee joint is innervated by bres of the lumbosacral plexus originating from the levels L2–3 (front of the knee) to S3 (back of the knee). The femoral nerve and saphenous nerve, the posterior branch of the obturator nerve and tibial and common tibial nerves send branches into the joint (Palastanga et al. 1994). Neurodynamic dysfunctions may contribute to movement disorders of the knee; for example, dysfunctions of the infrapatellar branch of the saphenous nerve, the saphenous nerve in the adductor canal of the thigh, the common peroneal nerve at the head of the bula and in the popliteal fossa (McCrory et al. 2002).
Pathobiological proces s es Most movement disorders treated by physiotherapists include overuse or misuse problems of the tibiofemoral joint and/ or patellofemoral joint with their intra- and extra-articular structures, posttraumatic disorders which may or may not have had a surgical intervention, degenerative conditions such as osteoarthritis of the knee and patients with a total knee arthroplasty.
Os te oa rthritis o the kne e O steoarthritis has been described as a degenerative articular disease affecting the cartilage, the underlying bone, soft tissues and synovial uid of the joint (Flores & H ochberg 1998). These changes result in alteration of the biomechanical properties (Sims 1999, Pearle et al. 2005) with changes of the tensile, compressive, shear properties and hydraulic permeability of the cartilage and increased stiffness of the subchondral bone (Flores & H ochberg 1998). The basic assumption that osteoarthritis is the result of mechanical ‘wear and tear’ processes has
least one of the following three items: ○ age > 50 years ○ morning stiffness < 30 minutes’ duration or ○ crepitus on motion • Within a classi cation tree in which knee pain and radiographic osteophytes or knee pain, age (> 40 years), morning stiffness and crepitus on motion are occurring together. H owever, the prevalence of knee pain and symptomatic knee osteoarthritis has increased signi cantly over a period of 20 years, while no such trend has been observed in radiographic knee osteoarthritis (Nguyen et al. 2011). It has been accepted that no direct correlation between radiographic changes and pain or disability may be present, although slow progression of the radiographic evidence and gradual increase of pain and disability may be indicative of progressive osteoarthritis (WH O 2003). Therefore, it is suggested that osteoarthritis be diagnosed more by its symptoms rather than by radiographic diagnosis alone (WH O 2003). The following de nition has been suggested: ‘osteoarthritis is a condition characterized by use-related joint pain experiences on most days in any given month, for which no other cause is apparent’ (WH O 2003, p. 55). In addition to pain, patients may complain about limitation of range of motion, crepitus, occasional effusion, local in ammation (Flores & H ochberg 1998), limitation of activity levels and reduced participation (WH O 2003). The changes in quality of life as a consequence of pain and the potential loss of independence in the elderly are a major concern (WH O 2003). Several domains are considered to be important in joint disorders such as osteoarthritis:
• Physical health: physical function, employment, pain and fatigue • Social health: social function • Mental health: emotional health, self-image, sexuality • Participation. 453
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The main health indicators are listed as follows:
• • • • • •
Pain or discomfort Mobility Physical activity or roles Ambulation Restricted participation Social activities or roles (WH O 2003).
Several risk factors or associated factors that contribute to the pain and disability have been described:
• Prolonged or repeated knee bending,
• •
• •
•
particularly in jobs entailing knee bending with mechanical loading (Cooper et al. 1994). This has been described in a study in the United Kingdom, but also in an observational study in Tibet it has been postulated that the prevalence of knee pain is high and may be related to squatting for longer periods, carrying heavy loads for long distances, wearing poor quality footwear and possibly poor nutrition (H oy et al. 2010) O besity, helplessness and severity of pain (Creamer et al. 2000) Physical inactivity, obesity, stress, smoking, family history, age (meaning that the condition is more common in elderly people) and joint trauma. It seems a greater problem among people of comparatively low socioeconomic status and is possibly associated with factors such as obesity (WH O 2003) Malalignment of the hip-knee-ankle angle during gait may be associated with progressive knee osteoarthritis (Sharma et al. 2001) It has been shown that quadriceps function is strongly associated with knee pain and disability. Anxiety and depression are more correlated than radiographic changes (O ’Reilly et al. 1998). In patients with symptomatic knee osteoarthritis it has been demonstrated that the quality of gait and the activation of the quadriceps muscle was less than in a control group, which was without symptoms (Rudolph et al. 2007) Muscle sensorimotor dysfunction (weakness, increased fatigability, proprioceptive de cits) may be implicated in the complex and multifactorial aetiology of osteoarthritis (H urley 1999, 2002).
Numerous guidelines have been developed for the treatment of knee osteoarthritis, in which speci c 454
movements and exercises are endorsed (Altman et al. 2000, Pendleton et al. 2000, O ttawa Panel 2005). Treatment should be aimed at optimizing general activity levels, working on weight loss, reducing smoking and optimizing diet. Treatment with a focus on movement endorsement aims to:
• optimize movement functions • restore overall functional capacity and performance • prevent recurrences of pain and disability • enhance tness and wellbeing • maintain independent, self-supported living in the elderly (WH O 2003, Moffat 2007). It has been acknowledged, that articular cartilage may have, albeit restricted, regenerative capacities. Therefore, the focus of treatment on local levels encompasses the building up of cartilage, tensile strength of bone and soft tissues in adolescent years. From middle age onwards, these activities should be focused on maintaining and optimizing the quality of bone, cartilage and ligament and their supporting, protective muscular structures. Therapeutic programmes should aim at graduated increase in weight bearing, particularly after periods of non-weight bearing or casting. The effects of unloading, loss of stiffness, and atrophy can be, at least partially, reversed with a gentle programme, which gradually increases the loading of all structures concerned (Lundon & Walker, 2007). It has been recommended that the mild forms of osteoarthritis should be treated in as early a phase as possible with a focus on the following aspects (Moncur 1996, Dieppe 1998):
• Aerobic endurance, cardiovascular tness • Improvement and/ or maintenance of joint mobility • O ptimization of motor control pattern to protect the joint structures • Normalization of movement patterns; for example, gait, walking up and down stairs • Information, education and instruction with regard to movement, diet, smoking, weight loss and other lifestyle factors, as well as self-management. As well as: • Proprioceptive qualities, such as joint position sense (Sharma et al. 1997, Felson et al. 2009).
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OA-re la te d re s e a rc h According to van Baar et al. (1998), speci c exercises have direct bene cial effects on pain and disability in patients with hip or knee. The exercises may be aimed at muscle strength, recruitment or coordination and endurance. Low-load repeated exercises, such as, for example, leg presses against low resistance, may in uence intra-articular metabolism and may support synthesis of new matrix macromolecules in cases of damage to the chondral matrix and/ or cells and/ or subchondral bone without visible disruption of the articular cartilage (Buckwalter 1998). Normalization of alignment and movement patterns during weight-bearing activities, such as walking and bicycling, are recommended to enhance equal distribution of loads over the joint structures (Moncur 1996, Sharma et al. 2001). Neuromuscular control of joint loading, including proprioceptive enhancement, is also recommended. Sharma et al. 1997 concluded in their comparative study of 28 patients with knee osteoarthritis and 29 controls, that the individuals with osteoarthritis demonstrated worse results on proprioceptive tests. H owever, Felson et al. (2009) tested proprioception by the accuracy of reproduction of the knee angle in persons with or at high risk of knee osteoarthritis. At 30 months’ follow-up they concluded that proprioceptive acuity could have moderate, but not strong, effects on the trajectory of pain and physical dysfunctions in knee osteoarthritis. Regardless of the somewhat inconclusive results, it seems to make sense to include balance and proprioception enhancement exercises in the treatment programme, as these exercises should enhance the patient’s con dence and functional self-ef cacy when moving in different circumstances and on various surfaces (H arrison 2004). There is evidence that a combined approach of active treatment with passive mobilization results in better and more lasting outcomes. Deyle et al. (2005), in a comparative study of patients with knee osteoarthritis, concluded that individualized manual therapy with supervised exercise may lead to greater symptomatic relief; this was also con rmed in a 12-month follow-up comparing the patients to the group which was only given a home exercise programme. Although both groups improved signi cantly when tested with six-minute walks and WO MAC scores, the people in the rst group were less likely to take medication for their pain and were more satis ed with the overall
outcome of treatment. In conclusion, it was recommended that a small number of additional clinical visits for the application of manual therapy and supervised exercise should be included in the treatment along with the home programme. Alamri (2011) concluded that manual therapy may enhance treatment outcomes, particularly in range of motion. In a comparative study between two groups, one group received manual therapeutic techniques and supervised exercise for a period of four weeks and the other group received only supervised exercises. Both groups improved signi cantly in WO MAC scores and VAS, but the group that had treatment including passive mobilization demonstrated larger signi cant results in range of motion. With regard to pain control, there is supportive evidence for the use of passive oscillatory mobilizations in the treatment of osteoarthritis of the knee. Moss et al. (2007) have provided experimental evidence that accessory mobilization of a human osteoarthritic knee joint has both an immediate local and a more widespread hypoalgesic effect. In a study of 38 subjects with knee osteoarthritis and mild or moderate knee pain, passive accessory movements were compared with manualcontact and no-contact interventions. Pressure pain thresholds were described as increasing signi cantly in the mobilization group, locally in the knee, but also more distally from the affected joints. Many patients with knee osteoarthritis may also show impairments in the hip, ankle or lumbar spine. Rocha et al. (2006) described in a clinical case study the treatment of the lumbar spine with severe knee pain. The rst six treatment sessions of the knee resulted in an improvement of perceived pain and the nal six sessions aimed at treating dysfunctions of the lumbar spine resulted in complete relief from pain at 12 months’ follow-up. In conclusion, it was recommended that the symptoms and signs of the spine be treated in addition to those of the peripheral structures. Currier et al. (2007) developed a clinical prediction rule for the integration of hip mobilizations in the treatment programme of knee osteoarthritis (in any combination of two variables):
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H ip or groin pain or paraesthesia Anterior thigh pain Passive knee exion less than 122° Passive hip internal rotation less than 17° Pain with hip distraction. 455
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The role of education and information has been investigated by H opman-Rock & Westhoff (2000) who conclude that a health education programme, which includes information on a healthy lifestyle and a physical education programme, demonstrated effects on pain, quality of life, muscle function, selfef cacy, BMI, physically active lifestyle and the number of visits to a physiotherapist. No effects were observed in range of motion and functional tasks. Regarding engagement in sports, tness programmes and moderate activity it has been shown, that: older adults participating for 20 to 30 minutes in moderate activity exercise on most days of the week have better physical function than older persons who are active throughout the day with daily cores or who are inactive. Any type of activity is better than no activity, but exercise confers greater bene t for physical capacity (Brach et al. 2004). There is indication that tai chi exercises may have bene cial effects on pain and disability of osteoarthritis (H all et al. 2009). Performance of the 12 forms of the Sun-style tai chi by older women for 12 weeks decreased arthritic symptoms and improved balance and physical functioning (Song et al. 2003). A moderate tai chi programme was shown to increase functional mobility and enhance arthritis self-ef cacy and quality of life in older adults with osteoarthritis. H owever, it appears that the quality of studies is relatively low with regard to RCT criteria. Hall et al. 2009, Hartman et al. 2000
Buckwalter (2003) recommends minimizing the risk of joint injuries and helping people with osteoarthritis to engage in regular physical activity, including low- or medium-impact sports (see the weblink in References for a list of sports in each category). H e postulates that lifelong participation in sports that cause minimal joint impact and torsional loading by individuals with normal joints and neuromuscular function does not increase the risk of post-traumatic osteoarthritis. In contrast, participation in sports that subject joints to high levels of impact and torsional loading increases the risk of joint injury and subsequent joint degeneration. H e suggests including the following measures to decrease the risk of joint injury and degeneration when participating in athletics:
• Selecting sports or exercise programmes with low levels of impact, torsional loading and injury 456
• Using equipment and playing or running surfaces that decrease joint impact and torsional loading • Maintaining and/ or improving muscle strength and endurance to decrease joint impact loading and protect joints from injury • Maintaining and/ or improving general conditioning to decrease the risk of joint injury due to fatigue • Alternate sports or exercise activities (cross-training) to decrease repetition of the same patterns of joint loading and motion. To conclude, it is important to customize the treatment of knee osteoarthritis to the individual symptoms and signs of the patient and to select an integrated approach with active and passive movement. Patient education should promote understanding of the role of associated factors and lifestyle and enhance motivation to move regularly. Movement programmes have to be individualized and adapted to the patient’s needs, preferences and movement potential. It is possible that short-term compliance to follow up with exercises and other self-management strategies is high in an early phase when supervised treatment is taking place; however, it may reduce once patients are performing independently (Campbell et al. 2001). With regard to exercise and activity it is crucial to allow the patient to experience the bene ts of a programme, as H urley (2002) passionately states: Even when delivered with whole hearted conviction, advising people to exercise will only have a limited effect on increasing people’s participation in regular physical activity. To get patients more physically active they must believe in the bene ts of exercise and believe they have the ability to perform the exercises effectively. To achieve this they need to experience the bene ts of a simple, practicable, and enjoyable rehabilitation regimen that can easily be integrated into their daily lives, and must include speci c advice how to continue exercising at home or in the community.
And, additionally: Exercise doesn’t have to involve strenuous, lengthy sessions in a gym. 30 minutes of accumulated physical activity is as bene cial as a strenuous jog, but should be performed on most, preferably all, days of the week. This physical activity could be accumulated during three 10-minute brisk walks, 30 minutes’ gardening or housework, or an enjoyable day out. For patients such advice is more achievable and acceptable than ‘going for the burn’ in a gym. It is more likely to increase compliance and deliver the psychological bene ts of exercise – increased feelings of self achievement,
Ap p lie d th e o ry a n d e vid e n c e s u p p o rtin g p ra c tic e self-con dence, self-esteem, and personal independence. Hurley 2002, p. 674
See also Chapter 8 on sustaining functional capacity and performance in H engeveld & Banks (2014).
‘Ante rior kne e p a in’ Anterior knee pain is a condition, which has received quite some attention in research and clinical practice since McConnell described a treatment approach for patella-femoral pain syndromes for this condition (McConnell 1996). It has been suggested to improve motor control patterns of the patella, particularly in the last 30° of knee extension and rst 30° of knee exion with emphasis on the relationship between the vastus medialis obliquus (VMO ) and the vastus lateralis (VL) of the quadriceps muscle acting as the primay stabilizing muscles in this range. It has been suggested that patients should train the recruitment of the muscle groups concerned within a closed or open kinetic chain with correction of pelvis-legankle alignment (Witvrouw et al. 2004, H errington & Al-Sherhi 2007). Corrective tapes may be applied to the patella if pain free exercising would not be possible (McConnell 1996). The training of the quadriceps with the emphasis on the VMO -VL relationship should occur within the chains of stabilizing muscle groups from the pelvis down to the knee and stabilisers of the foot (Cowan et al. 2002). Increasing attention is given to the role of the popliteus muscle within the overall dynamic chain of the pelvis and leg complex (Nyland et al. 2005). Various effects have been attributed to the role of patellar taping the rehabilitation of patellafemoral symptoms. H owever it appears that the main, consistent effect lies in the reduction of pain during exercising (Crossley et al. 2000). The effect of physiotherapeutic treatment on the electromyographic (EMG ) timing of the activity of the vasti with the correlation of pain reduction was investigated in 65 participants diagnosed with patella femoral pain syndrome. It was concluded that before treatment the EMG onset of the VL occurred earlier than that of VMO in the treatment group and a control group. After treatment the onset of VMO preceded VL in the eccentric phase and occurred at the same moment in the concentric phase, while in the control group no EMG changes were demonstrated. This improvement of EMG function was associated the reduction in symptoms (Cowan et al.
2002). Next to muscular recruitment training, also passive mobilization and soft tissue techniques of the patella appear to lead to bene cial outcomes regarding pain on a short term basis. Van den Dolder and Roberts (2006) investigated the effects of six sessions of manual therapy (joint mobilization and soft tissue techniques) in one group, while the control group remained on a waiting list for two weeks. The experimental group improved signi cantly with regard to pain, active knee exion range of motion, pain and velocity while walking stairs. In spite of the attention to the localized treatment and improvement of motor control patterns, it is important to consider other sources and contributing factors to the onset, development and maintenance of anterior knee pain. Pain in this area may result from nociceptive (and peripheral neurogenic) mechanisms of the lumbar spine, pelvis, hip, neurodynamic processes and soft tissues as for example trigger points. These components need to be incorporated in examination, before a comprehensive, multimodal treatment programme may be developed for this condition (Collins et al. 2012). Further information on the clinical pro le may be found in Tables 8.1 and 8.2 and Case Study 8.1.
Tota l kne e re p la c e me nt Total joint replacements are a common surgical intervention in many degenerative, in ammatory types of osteoarthritis and in some post-traumatic situations. Although many protocols describe maintenance and improvement of joint mobility as one of the treatment objectives, they are not explicit in the use of active, assisted active (or assisted passive) or passive movements (Moncur 1996, Atkinson et al. 1999, Trudelle-Jackson et al. 2002, Thomas 2003). G entle passive mobilizations may complement the postoperative treatment. H owever, they may need an approach of ‘wise action’ (H iggs & Jones 2008; see also Chapter 2 on clinical reasoning in H engeveld & Banks 2014) bearing in mind with the following considerations:
• Employ mainly accessory movements • Localization of forces should be as close as possible to the joint line • Application of forces should take place as much as possible parallel to the line through the joint surfaces 457
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Table 8.1 Clinical prof le: osteoarthritis
Examination
Clinical evidence and ‘brick wall’ thinking
Kind o disorder
Pain and restricted mobility in various daily li e activities
Body chart eatures
The patient may grasp around the knee and indicate that the pain is elt deeply in the joint or in the bone. Pain which is elt more superf cially at the anterior side may indicate that movements o the patella are pain ul as well
Activity limitations and 24-hour behaviour o symptoms
Getting up rom a deep chair, walking up and down stairs, walking or longer periods Patient indicates that neither too much activity nor too little are benef cial – needs to f nd a balance between active and rest periods. Pain may be strong at night (vascular mechanisms?)
Present and past history
Gradual onset o symptoms in a prolonged history o constant awareness o discom ort studded with exacerbations Some patients indicate that the pain and disability increased over time and they may not be symptom ree anymore. With those patients symptoms may have progressed rom occurring during weight-bearing activities towards symptoms at rest (especially at night). However, other patients may describe that they have improved over the years, as, or example, a ter retirement rom sedentary work, more activities (e.g. walking) are being per ormed
Special questions Source or mechanisms o symptom production
Pain originating rom the subchondral bone exposed by symptom production o ull thickness de ects. Capsular and ligamentous structures may cause nociceptive activity Neurogenic and intra-osseous vascular mechanisms may contribute to the pain
Cause o the source Contributing actors
Habitual gait patterns, loss o joint mobility (esp. in extension), loss o muscle strength (e.g. coming up rom squatting not per ormed or years), reduced aerobic condition
Observations
Genu varum, valgus position possible. Wasting o quadriceps, gluteal muscles; tight iliotibial band
Functional demonstration o active movements
Weight-bearing activities (e.g. getting up rom a chair) and squatting may provoke symptoms. Di erentiation testing o the tibio emoral and patello emoral joints is requently possible. O ten, however, both joints involved. Flexion, extension, rotations (esp. under compression) may be pain provoking. O ten with through-range f ndings, crepitus may be present (may be deep in tibio emoral joint or more superf cial in patello emoral joint)
I necessary tests
See above: compression
Other structures in plan
Relation to lumbar movement dys unction; hip, neurodynamic structures
Isometric and muscle length tests
Mostly inconclusive regarding symptom reproduction as contributing actors usually weak
Neurological examination Neurodynamic testing Palpation f ndings
Tenderness o so t tissues surrounding the joint
Passive movement, accessory/ physiological combined movements
Accessory and physiological movement o tibio emoral (and perhaps patello emoral) joints may be pain provoking and restricted. Compression may elicit crepitus and increase pain
458
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Table 8.1 Clinical prof le: osteoarthritis—cont’d
Examination
Clinical evidence and ‘brick wall’ thinking
Mobilization/manipulation techniques pre erred
Accessory movement at end o range and through range positions. Large amplitudes, progression to compression may be necessary. I the problem is stable, physiological movements, particularly in extension combinations, may be utilized
Other management strategies
NSAIDs and pain-relieving medication i necessary; improvement o aerobic conditioning (e.g. on ergometer without resistance), muscle control, habitual (gait) movement patterns. Encouragement to exercise regularly, maintaining mobility, muscle strength, aerobic condition; pain-coping strategies, e.g. with automobilizations, repeated movements
Prognosis and natural history
Functional limitations may be in uenced avourably with active and passive movement therapies in spite o the presence o degenerative changes in X-ray f ndings
Evidence base
It has been demonstrated that passive oscillatory techniques applied to the knee in uence perceived pain (Moss et al. 2007). It has also been shown that active exercises have benef cial e ects on outcomes such as pain, mobility and unction (Moncur 1996, van Baar et al. 1998). However, there is an indication that a combined approach using both active and passive treatments leads to better long-term outcomes than either active or passive techniques used alone (Deyle et al. 2005, Alamri 2011)
Table 8.2 Anterior knee pain (due to peri- or intra-articular patello emoral movement disorders)
Examination
Clinical evidence/‘brick wall’ thinking
Kind o disorder
Symptoms in anterior area o knee, may limit daily li e activities strongly
Body chart eatures
Symptoms may be elt superf cially in area o patella or more deeply underneath patella
Activity limitations and 24-hour behaviour o symptoms
Squat, getting up/down stairs, bike riding, downhill skiing, jumping may be mildly/severely restricted due to pain
Present and past history
Symptoms may have developed gradually, usually in periods o growth spurts and active integration in sports (e.g. running). May occur post-traumatic (e.g. a ter a all on the knee, as in volleyball)
Special questions Source or mechanisms o symptom production
(Peri- and/or intra-articular oriented) patello emoral movements or the so t tissues surrounding the joint may be causes o the nociceptive processes
Cause o the source Contributing actors
Muscle imbalance: recruitment pattern o VMO disturbed. VMO activity to late responses. Abductors o hip, pronation position o oot in uence activity o VMO Contribution o Q angle inconclusive
Observations
Postural analysis is essential – alignment o tibia to emur; pronation o oot? Medial rotation pelvis or retraction o pelvis?
Functional demonstration o active movements
Squatting, getting down stairs. Observe quality o the movement: leg may all into adduction and medial rotation o the hip. Pain may occur especially between 0 and 60° o exion. Pain provocation with hip extension and adduction or position o lateral tibial rotation: indicative o short and tight tensor asciae latae and iliotibial bands
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Table 8.2 Anterior knee pain (due to peri- or intra-articular patello emoral movement disorders)—cont’d
Examination
Clinical evidence/‘brick wall’ thinking
I necessary tests Other structures in plan
Relation to lumbar movement dys unction, hip, neurodynamics
Isometric or muscle length tests
Tests o quadriceps, VMO in particular may provoke pain; coordination changes
Neurological examination Neurodynamic testing Palpation f ndings
So t tissue tenderness. Patella position in 20° o exion: parallel to rontal and sagittal planes? Midway between emur condyles?
Passive movement, accessory/ physiological combined
Accessory movements o patello emoral joints may provoke symptoms, including crepitus, especially i compression is applied movements
Mobilization/manipulation techniques pre erred
Accessory movements; i very pain ul (group 1) gentle, large amplitude techniques short o P1. Progression: in other positions o F and F/Ab o the knee; in later stages compression may be added. Lateral retinaculum may need to be stretched (e.g. in side lying and adding transverse medial movements and rotary movements along a longitudinal axis)
Other management strategies
Normalize tracking o patella in emoral groove with recruitment exercises o VMO within the muscle chain o oot and pelvis. Stretch tight iliotibial bands and tensor asciae latae. Corrective taping o patella (medial; rotary; tilting cephalad, medially) may be help ul i weight-bearing exercises are too pain ul. Condition: corrective tape has to reduce the pain
Prognosis and natural history
’The need or surgery or patello emoral pain has almost been eliminated due to improved understanding o its aetiology, taping o the patella to reduce the symptoms, and specif c training o the VMO and gluteals. However the patient needs to be aware that the symptoms are managed … and the pain may recur, particularly when the activity level has increased and there has been a lapse in the exercise program’ (McConnell 1996, p. 65)
Evidence base
McConnell 1996, Stiene et al. 1996, Witvrouw et al. 2004, Herrington and Payton 1997, Ernst et al. 1999
• Long leverage or techniques, which may move the bone around the prosthesis should be avoided (e.g. longitudinal caudad movement localized at the distal part of the tibia in knee treatment, distal part of femur in hip movement, distal part of humerus in shoulder movement) • Progression of treatment is possible as described on pages 481–485. If active movements achieve the goals of treatment, passive movements become super uous. H owever, in an early phase after the operation in which the focus lies on active movement within pain-free limits, gentle passive movements may support the active movement of the patient, e.g. many patients with a joint replacement of the hip may have 460
dif culties with active exion of the knee in supine lying. G entle AP movement, applied to the joint, may ‘centralize’ the hip better which then allows the patient to actively ex further into the range; many patients with a knee arthroplasty may have dif culties, and/ or pain, in actively exing and extending the knee in sitting. G entle accessory movement applied closely to the joint may enhance the movement. In later stages, when tissue healing is nearly complete and joint mobility seems more restricted than would be expected in this phase, passive movements may become the rst treatment of choice to enhance mobility. It appears that gentle passive movements as a support to active motion are underutilized in physiotherapy practice in the postoperative treatment of
S u b je c tive e xa m in a tio n
total knee arthroplasty. This may be due to the dominant biomechanical perspective on the effects of passive movements. H owever, it has been demonstrated that these theories have not found an acceptable scienti c basis (Twomey 1992). Particularly neurophysiological effects have received much attention in many publications (Wright 1995). In the case of total knee arthroplasty, passive movements may be considered in the light of central learning theory and neuroplasticity: 1. Input by repeated stimuli (for example, oscillatory passive movement and its progression) would lead to a desensitization of the nervous system with restoration of normal system sensory processing 2. Based on central learning theory and neuroplasticity, habituation of sensomotor processes, in which synaptic learning would lead to decreased behavioural responses to repeated stimulation 3. Averse memory – extinction of protective, unfavourable sensomotoric patterns, by offering the nervous system different, normal sensomotor stimuli with passive and active movements (Zusman 2004).
Clinic al re as o ning Most disorders of the knee treated by physiotherapists include overuse or misuse problems, such as patellofemoral pain syndrome (PFPS), traumatic injuries and degenerative conditions such as osteoarthritis of the knee. Frequently the problems are based on dominant nociceptive processes, which may need to be treated with passive mobilization to normalize joint function, muscle control exercises, aerobic endurance, agility and proprioceptive training and restoration of functional activities. It is crucial to consider all possible movement components contributing to the pain and disability of the patient, as well as factors relating to compliance enhancement and motivation to change, in order to individualize treatment. The reader should refer to Chapter 1 of this volume and Chapter 2 of Vertebral M anipulation for a description of clinical reasoning and clinical reasoning theory. The clinical pro les in Tables 8.1 and 8.2 demonstrate how different hypotheses categories may be implemented in the procedures of examination and treatment of some common movement disorders of the knee.
Subje c tive e xaminatio n Subjective examination, as in all other areas of movement dysfunctions as described in this book, is essential to determine the possible sources of symptoms, contributing factors, precautions and contraindications to examination and treatment procedures and the overall level of disability, leading to treatment objectives in activity and participation levels as described in the International Classi cation of Functioning, Disability and H ealth (ICF) (WH O 2001). The main movement components to be analyzed during the subjective and the physical examination are:
• Tibiofemoral joint, including peri- and intraarticular structures • Patellofemoral joint, including peri- and intra-articular structures • Soft tissues (if not to be localized as periarticular structures of the above-mentioned joints) and musculotendinous structures • Superior tibio bular joint (often needs to be examined in foot and ankle disorders as well). H owever, if symptoms appear vague and dif cult to localize or the symptoms have not developed based on a clear incident, other contributing components (e.g. hip joint, lumbar spine, neurodynamic system) to the movement disorder also have to be taken into consideration. This may also be the case in those circumstances where an injury has led to the symptoms but recuperation of function seems to take longer than would be expected. Important points in the subjective examination include (Corrigan & Maitland 1994):
• Whether the onset of pain is gradual or sudden • The relationship of pain to any trauma and the • • • • • • • •
mechanism of such trauma The presence of any swelling and how rapidly or gradually it developed A feeling of instability or ‘giving way’ during use Any locking of the knee Clicking or catching, especially if it reproduces pain Whether the knee problem is stable, progressive, recurrent or intermittent, or brought on by certain activities The presence of any stiffness Whether other joints are involved The effects of any previous treatments. 461
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Main problem (‘Ques tion 1’) Next to pain, the patient may describe various other complaints as the main problem.
Loc king A careful evaluation of this symptom is essential. Locking may result from a torn meniscus, a loose bony fragment (e.g. from osteochondritis dissecans), a torn cruciate ligament or avulsed anterior tibial spine, chondromalacia patellae, a dislocated patella or a medial plica. Locking is not an appropriate term as it implies that no movement at all should be possible. Locking usually means a sudden complete block to full extension of the knee which is nevertheless able to ex fully. The knee usually lacks 30° of extension and the screw-home mechanism is lost. The end-feel extension in a locked knee provides a characteristic rubbery sensation with an associated motor response (spasm).
Ca tc hing Catching is a sensation which indicates that something is getting in the way of joint movement and it may be painful. Its mechanism of production is similar to locking.
Ins ta b ility – ‘giving wa y’ Stability is provided by the ligamentous structures (passive stability) and the surrounding muscles (dynamic stability). A feeling of instability, giving way or ‘buckling’ of the knee on use is a common symptom. It may be produced in chondromalacia patellae, a torn meniscus, a loose bone foreign body or arthritis. A feeling of instability may also arise after cruciate ligament tear with true rotatory instability. The knee usually gives way suddenly without any warning or pain, but often with a feeling that one bone has moved or slipped on the other. This tends to occur on walking down stairs or on uneven ground when the leg supports the body weight. It is particularly common when a runner changes direction or steps off the involved leg.
Swe lling Swelling indicates the presence of some intraarticular damage. H aemarthrosis comes on more rapidly after injury than synovitis so that its onset is 462
measured in minutes rather than hours. The knee is usually extremely painful, warm, tender and held in some degree of exion. The most common cause of a haemarthrosis is a ruptured anterior cruciate ligament. Less common causes are tears in the capsular ligament or an osteochondral fracture. Non-traumatic causes are rare and include blood dyscrasias, anticoagulant therapy, pigmented villonodular synovitis or neoplasms. H aemarthrosis may need to be differentiated from crystal deposition diseases, in ammatory arthritis and septic arthritis. Diagnosis is then made after aspirating the knee of synovial uid.
Areas o s ymptoms (body chart) The localization of symptoms may be indicative of the movement component causing the symptoms.
• Disorders from the tibiofemoral joint usually produce pain within the knee itself. The patient may grasp around the knee and indicate that ‘it’ is deep within. The pain may be associated with stiffness, especially after sitting for a time • Disorders of the patellofemoral joint usually produce pain in the retropatellar area or the anterior side of the knee and are more super cially indicated than disorders from the tibiofemoral joint. O ccasionally some symptoms may be felt deep in the knee fold on the posterior side • Soft tissue lesions (e.g. of ligamentous structures or tendons and their insertions) are often felt locally and the patient may be able to pinpoint the painful spot by touching it. Pain may also be felt in the knee area as a result of dysfunctions in more proximal structures. Frequently this type of pain is more vague, dull and more dif cult to localize. In particular, the hip joint may refer to ventromedial areas of the knee, while the lumbar spine may radiate to the dorsal side. In certain circumstances dysfunctions of neurodynamic structures may contribute to the symptoms.
Behaviour o s ymptoms – activity limitations While hypotheses with regard to the sources of the symptoms may already have been generated during the rst phase of the subjective examination, the behaviour of the symptoms and the concomitant
P h ys ic a l e xa m in a tio n
activity limitations may serve to modulate or con rm some of these hypotheses (principle: ‘make features t’):
• Symptoms arising from the tibiofemoral joint are often worse when the patient rst stands up to walk or after walking for some distance, are often worse with weight bearing on the affected leg and are worse on going up or down stairs. Pain may also be associated with stiffness, particularly after sitting for a time. • Disorders of the patellofemoral joint are usually made worse by activities such as walking, running, riding a bicycle, going up stairs or walking downhill for some time. The symptoms may also occur after a prolonged period of sitting, for example, in a car or at the theatre. • Local ligamentous lesions may be provoked with activities which involve stretching the ligament concerned. Furthermore, tendinous lesions may be provoked with activities involving contraction of the muscle or stretching or compression the tendon. It is essential to establish the current levels of activities and the preferred levels of activities. Particularly in cases of osteoarthritis of the knee activities as walking, climbing stairs, self-care, carrying bags, bending, kneeling and so on need to be established in suf cient detail in order to allow for the development of an individualized treatment programme based on the patient’s complaints, functional limitations and movement preferences.
His tory If the symptoms are of traumatic onset, information on the injuring movement is essential. In acute cases it may give an indication of the structures involved. If total ligamentous ruptures, torn menisci or fractures are suspected, the physiotherapist may need to consult a medical practitioner before continuation of treatment. If symptoms are more minor, or the disorder has recuperated to a degree, and it no longer limits most daily life activities, the injuring movement may become an essential element of physical examination and may be used in treatment with passive mobilization (Maitland 1991). If symptoms are of spontaneous onset, it is necessary to investigate if any overuse or misuse of the structures or reduced capability to bear stress (e.g. due to muscular imbalances or lack of aerobic
condition) has contributed to the development of the nociceptive processes. In cases of pain in the inferior patellar area the activities leading to the symptoms may give an indication of the possible structures involved:
• Eccentric loading (e.g. jumping in ball sports or increased hill work during running) mainly provokes the patellar tendon. • Symptoms developed after tumble turning or vigorous kicking in a swimming pool may indicate the presence of an irritated fat pad (McConnell 1996).
Medical and health s creening ques tions Next to the routine information regarding the patient’s health, weight loss, radiographic ndings, medication intake and so on, screening questions should be posed with regard to vascular and neurogenic disease such as varicosis, deep venous thrombosis or polyneuropathy (see also Chapter 2 on clinical reasoning in H engeveld & Banks 2014).
Phys ic al e xaminatio n Depending on the plan after the subjective examination, the physiotherapist may decide to focus the examination on one of the main components of the joint, be they tibiofemoral, patellofemoral or superior tibio bular movements. First, active movements will provide the therapist and patient with parameters for reassessment procedures. The components may be examined passively, with subsequent reassessment of the active parameters to con rm the possible involvement of one or more components in the movement disorder. If soft tissue lesions are suspected, it is often recommended that the joint components be examined rst, as they frequently constitute a part of the periarticular structures which may be in uenced by mobilizations with accessory and physiological movements. In many cases screening of movement functions of hip, lumbar spine and neurodynamic structures is necessary. Box 8.1 provides an overview of examination procedures of the knee complex and its related structures. Detailed information on some test procedures is given below. 463
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Box 8.1 Physical examination o the knee complex Ob s e rva tion • Firs t palpation o temperature, s welling or e us ion • Pres ent pain *Func tio nal de mo ns tratio n/te s ts , including di erentiation o movement components Brie apprais al Active movements • Gait analys is : orwards , backwards , on heels (es p. backwards ), on toes ; may as s es s : s print, running • Squat: on toes , on heels , bouncing • Height o s tep • Quadrupedal pos ition: s it towards heels • Getting up or down a s tep ( orwards , backwards , s ideways ) • Hopping, jumping • Extens ion o knee in s tanding • In s upine, lying, including overpres s ure: • F, E, in 90° F, MR and LR • ‘I neces s ary’ tes ts : F/Ab, F/Ad, incl. combinations in rotation; F + Ab, F + Ad E/Ad, E/Ab (= E with on tibia) In di erent pos itions o F or E: MR, LR Ab/Ad (in E and 20° F) ‘Injuring movement’ Mus cle tes ts • Is ometric tes ts : s ymptom reproduction. Quadriceps , biceps emoris , s emitendinos us , s emimembranos us , adductors • Recruitment patterns : VMO, VL in di erent pos itions o F in s tanding • Mus cle length tes ts (mos tly at end o pas s ive tes ting – a ter neurodynamic tes ting) • Motor control and recruitment patterns : VMO, VL, etc. Screening o other s tructures in ‘plan’ • Hip, lumbar s pine, s acroiliac joint, neurodynamic s tructures
Pres ent Pain Before performing any tests it is necessary to determine if the patient has any pain at rest.
Obs ervation The patient must be suitably undressed. If possible the observation will be done rst in weight bearing. It includes observation of: 464
Palpation • Temperature, s welling, e us ion • Tendernes s Pas s ive movements • Neurodynamic tes t procedures • Movement diagram o relevant active tes ts : F, E, in 90° F, MR or LR • Menis cus tes ts , ligamentous tes ts (s tability tes ting) • Tibio emoral joint: • Phys iological movements : F combinations ; E/Ab, E/Ad as treatment technique • Acces s ory movements : Ab, Ad (in E and 20° F), , , , , caud and ceph , • Tes t procedures under compres s ion • Patello emoral joint: • Acces s ory movements : caud and ceph, • , , , dis traction, , , longitudinal and s agittal • In di erent pos itions • Tes t procedures under compres s ion • Superior tibiof bular joint: • Acces s ory movements : , , caud and ceph, , • In di erent pos itions , incl. SLR and invers ion o oot (common peroneal nerve) • Tes t procedures under compres s ion Check cas e records etc. Highlight m ain ndings with asterisks Ins tructions to patient at end o s es s ion • Warning: pos s ible exacerbations • Ins tructions : obs erve and compare s ymptoms and activities • Other recommendations : s el -management s trategies , etc.
• Any kind of structural changes, swelling, temperature • Is weight bearing symmetrical? Are any aids used in weight bearing? • Alignment of the legs, the pelvis and the spine • Willingness to move.
Alignme nt When patients present with knee problems the assessment of the alignment is an important point
P h ys ic a l e xa m in a tio n
in the assessment of contributing factors. The assessment of the alignment should include multiple alignment characteristics which may interact with or cause compensations at other bony and soft tissue segments (Nguyen & Shultz 2009, Daneshmandi & Saki 2009). Lower extremity alignment has been shown to be a risk factor for knee injury especially in females (Loudon et al. 1996) and for structural progression of knee osteoarthritis (Brouwer et al. 2007, Sharma et al. 2001) and patellofemoral problems (Powers et al. 2012). The assessment of the alignment includes not only the orientation of bony landmarks but also the muscular and fasciae contour. In clinical practice six alignment measurements are commonly used.
• The quadriceps angle (Q -angle) is formed by a caudally oriented line from the anterior superior iliac spine (ASIS) to the patella centre and a line from the patella centre to the tibial tuberosity and can be measured in lying, standing and one-leg standing. Normal Q -angle values for women are < 20° and for men <15° (H orton & H all 1989, McKeon & H ertel 2009). Alterations of the Q -angle in uence the tibiofemoral and patellofemoral kinematics (Mizuno et al. 2001). Q -angle is in uenced by pelvic, hip, knee and foot position and their related muscular control. Shultz et al. (2006) reported an intra-class correlation coef cient (ICC) of 0.89 to 0.98 intra-tester reliability. The Q -angle determines the lateral pull of the quadriceps on the patella. Clinically relevant is the dynamic Q -angle in one-leg standing or squatting (Massada et al. 2011). In addition, the alignment of the patella in relation to glide, tilt rotation and anteroposterior tilt has to be assessed. This is done in standing but later on also in supine position with the knee in a slight exed position. Kalichman et al. (2007) have shown that patellar malalignment can cause excess stress on the articular surfaces of the patellofemoral joints and may be a reason for degenerative changes in the knee. • The tibiofemoral angle is measured by the intersection of the axis of the femur with the axis of the tibia. A varus-aligned (bow-legged) individual has a tibiofemoral angle less than 5° valgus. Normal alignment is 5–7° valgus. A valgus-aligned (knock-kneed) individual has a
tibiofemoral angle greater than 7° valgus (Karachalios et al. 1994). Sharma et al. 2001 showed that individuals with a varus knee alignment have an increased risk of medial compartment and individuals with a valgus knee alignment have an increased risk of lateral compartment osteoarthritis progression.
• N avicular drop test (Brody 1982): in a seated position with the knees and hips at 90-degree angles the subtalar joint neutral position is found. The distance of the midpoint of navicular tuberosity of the foot to the oor is measured. The subject then stands up and the standing navicular position is measured. Navicular drop is calculated as the difference between the sitting and standing positions. This method has been reported to have an ICC of 0.91 to 0.97 for intra-tester reliability (Shultz et al. 2006). The minimum (Trimble et al. 2002) and maximum (Moul 1998) reported average measurements for navicular drop test are 7 and 9 mm, respectively.
• G enu recurvatum is measured, if possible, in standing; the patient is asked to extend the knee as fully as possible. Measurement is taken from the central point of the greater trochanter to the central point of the lateral femoral epicondyle and from the most lateral point of the proximal joint line of the knee through the lateral malleolus (McKeon & H ertel 2009). This method has been reported to have an ICC of 0.88 to 0.97 for intra-rater reliability. The range of averages reported for tibial varum for healthy limbs is 4° to 8.7°. More than 10° of knee hyperextension is a potential risk factor for overuse injuries in the lower limb (Devan et al. 2004).
• Anterior pelvic tilt is measured using an imaginary line from the anterior superior iliac spine to the posterior superior iliac spine as it diverges from the horizontal. Pelvic tilt is measured as the degree of anterior tilt of the pelvis in the sagittal plane. This method has been reported to have an ICC of 0.77 to 0.99 for intra-tester reliability (Shultz et al. 2006, Krawiec et al. 2003). The average anterior pelvic tilt angle is 10–15° (Shultz et al. 2006).
• Femoral anteversion is measured with the patient positioned prone and the knee exed to 90°. The greater trochanter is palpated at its most lateral position (passive femur internal 465
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rotation is used to nd this position). Femoral anteversion is determined as the acute angle formed by the tibia and an imaginary vertical line. Shultz et al. (2006) reported an ICC of 0.77 to 0.97 for intra-tester reliability of the femoral anteversion test. Normal femoral anteversion values range from 8°–15° (Magee 1987). It has been described that women demonstrate larger measures for Q -angle, genu recurvatum, anterior pelvic tilt and femoral anteversion compared with men (McKeon & H ertel 2009). O ther aspects that may be considered during observation are: • Any indication of swelling or an in ammatory process (in some cases it may be important to commence the observation with a quick palpation of temperature and swelling. If found positive, as a precautionary measure the tests should be repeated regularly during the steps of physical examination to ensure that the temperature and swelling do not increase due to the testing procedures (see ‘Palpation’ below) • Any indication of muscular imbalance and wasting (e.g. weakness of the vastus medialis and hip abductors, shortened iliotibial band). Be aware to assess the trunk as well as the lower limb. Current evidence suggests that decreased core stability may predispose to injury of the lower extremity (Willson et al. 2005).
Functional demons tration tes ts The patient is asked to demonstrate a functional activity which provokes the pain as described in the subjective examination. This activity may serve as a functional reassessment parameter (‘physical asterisk’). Differentiation procedures may also be performed, which add or subtract stress to the movement components involved in the activity. For example, the patient may demonstrate symptoms at the medial side of the knee during the demonstration of a tennis movement (forehand). The patellofemoral joint may be examined when medial or lateral gliding movements, including compression, are added to the activity. The tibiofemoral joint may be additionally stressed by increasing, for example, the medial rotation of the femur over the tibia, and the hip joint may be put under more stress (while at the same time the therapist controls the knee joint to control 466
its position) by rotatory movements of the pelvis over the femur. Changes in symptoms during the manoeuvres indicate the movement component(s) responsible for the symptoms.
Brie apprais al After the differentiation tests a brief appraisal or re ection is necessary in which the physiotherapist determines if the test procedures may be continued as planned or if an adaptation of the examination sequences seems necessary.
Active movements We ight b e a ring It is recommended to include active movement tests of the knee in weight bearing (unless contraindicated) before performing active tests in supine or prone lying.
• G ait analysis. Some aspects of gait analysis
•
•
•
•
have been described in Chapter 7. In the examination of movement disorders of the knee, particular attention should be given to walking forwards, backwards, walking on heels (especially backwards) and walking on toes. If necessary, gait analysis is performed at different speeds. In sports people often running and sudden changes in direction also need to be assessed. Standing on one leg. Special attention should be given to the alignment of the pelvis, hip, knee (Q -angle) and foot. Muscular activation (decreased or increased) and possible recruitment faults should be assessed. Standing on one leg and half or full exion test. The full exion test is only performed if symptoms have not yet been reproduced and the problem presents as stable. Most commonly it is used to test sports people. Standing on one leg and rotation test. This test can be used to increase the rotational stress on the knee joint if symptoms have not yet been reproduced. Step-up and step-down test forward, backward and to the side. As with the one-leg standing test, special attention should be given to the alignment (functional Q -angle; pelvic, knee and foot alignment) and muscle activation.
P h ys ic a l e xa m in a tio n
• Squatting on toes (knee squat), on heels (hip squat). Assess quality of movement, amount of movement and symptoms. If necessary, progress to bouncing and bouncing sideways (with the pelvis laterally and medially from the affected knee). • Sitting on heels. The patient moves from the quadruped position gradually from the buttock towards the heels. The same test can be done starting in the kneeling position. • Active knee extension in standing. The patient should place both feet in line with the centre of the hip joint and move both knees in active extension or hyperextension. If necessary, a light bounce can be performed. • H opping, jumping on both legs or one leg. If necessary, the stress on the knee joint can be increased by hopping, jumping on both legs and one leg or any other sport-related activities, which might be relevant for assessment.
A
B
Ac tive te s ts o the kne e (in non-we ight b e a ring) The active movement tests of the knee joint in nonweight bearing are done if the active tests in weight bearing are not indicated or if range of movement has still to be measured. The standard tests include extension, exion and in 90° of exion, medial and lateral rotation. O verpressure may be added at the end of range of active movement if symptoms are not reproduced.
Extension (supine) • The patient actively extends the knee. O bserve range, quality (including muscle recruitment patterns) and symptom reaction. • O verpressure should be applied in three different ways: 1. Towards the proximal aspect of the tibia (Fig. 8.1A) 2. O ver the distal aspect of the femur (Fig. 8.1B) 3. O ver the joint line (Fig. 8.1C).
• The end-feel may be appreciated in a different way, i.e. with the knee fully extended and relaxed. Passively ex the knee approximately 20° and then allow it to drop back into full extension. A normal knee can fall into full extension with a typical painless hard end-feel.
C
Fig ure 8.1 • Extension overpressure applied: A to the tibia; B to the emur; C over the joint line.
In patients with osteoarthritis a similar end-feel may be found, but the joint lacks full extension. A meniscus lesion may produce a softer end-feel and the leg may bounce slightly more once dropped from exion to extension.
Flexion (Fig. 8.2) • The patient is asked to pull the knee towards the buttock. O bserve range, quality and symptom response. • Mobility may be measured with a goniometer, but as an alternative the distance between the heel and the ischial tubercle may be measured in centimetres. 467
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• Test movements may be produced under compression (see ‘Passive test procedures’ below).
Mus cle tes ts Muscle tests may be performed with different purposes:
• Symptom reproduction • Muscle strength, endurance, coordination and recruitment patterns • Muscle length.
Is ome tric te s ts – a s s ymp tom re p rod uc tion Isometric tests are carried out if muscle or tendon lesions are suspected. The tests frequently need to be combined with palpation of the tender spot(s) to con rm the structure at fault. The following structures may frequently cause symptoms and require soft tissue treatment:
• Biceps femoris with the insertion at the bular Fig ure 8.2 • Flexion overpressure.
In 90° o f exion: media l r ota tion, la ter a l r ota tion • The test may be performed in supine (Fig. 8.3),
head • Q uadriceps, with the patellar ligament • Adductors as part of the pes anserinus. N ote: If soft tissue lesions occur in conjunction with joint dysfunctions, it is recommended that joint signs are treated rst, with the isometric painprovoking tests used as one of the parameters in reassessment procedures.
as well as in sitting.
I ne c e s s a ry te s ts These need to be performed if the ‘standard’ tests insuf ciently produce symptoms. Usually combinations of physiological movements are performed, either passively or assisted actively, as follows:
• Produce medial and/ or lateral rotation in different positions of exion and extension. • (Passive) abduction, adduction (see ‘Description of techniques’ below). • Extension/ adduction, extension/ abduction (including anteroposterior movement on the tibia) (Fig. 8.4). • Flexion/ abduction, exion/ adduction, including combinations in rotation (see ‘Passive test procedures’ below) (see Fig. 8.5). 468
Re c ruitme nt p a tte rns , p a te lla r a lignme nt a nd s ymp tom re p rod uc tion The recruitment of the vastus medialis oblique (VMO ) in weight-bearing positions merits particular attention in movement disorders of both the tibiofemoral and the patellofemoral joints. In different positions of high sitting (e.g. 0°, 20–30°, 60°, 90°) the following factors may be observed (H ilyard 1990):
• Symptom reproduction • Patellar movement: does correction of the patella (manually or with tape) reduce the symptoms? • Q uadriceps activity within the overall muscle chain: timing and amount of activity of VL versus VMO. Is there earlier and greater
P h ys ic a l e xa m in a tio n
A
B
Fig ure 8.3 • Active rotation, including overpressure: A medial; B lateral.
A
B
Fig ure 8.4 • I necessary tests: A extension/adduction; B extension/abduction.
amount of activity in VL? McConnell (1996) proposed that there should be an equal amount and similar timing in the VL and VMO. A delayed onset of VMO in relation to the vastus lateralis was observed in subjects with PFPS
(Cowan et al. 2002, Tang et al. 2001). In management, VMO training will be an important part of therapy if there is a difference between VL and VMO (Fig. 8.6). 469
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A
B
Fig ure 8.5 • Tibio emoral movements in f exion: A f exion/abduction; B f exion/adduction.
gluteus maximus) and poor stability of the foot is commonly associated with knee joint problems (especially with patellofemoral problems) (Powers 2010, Prins & van der Wurff 2009).
Muscle length tests Tests of the rectus femoris, tensor fasciae latae (including iliotibial band), hamstrings, adductors, gastrocnemius and soleus may be performed in this stage of the examination. H owever, it is often recommended that an impression of the mechanosensitivity of the neurodynamic system should be obtained rst (Edgar et al. 1994) and that muscle length tests be performed during the sequence of passive movement testing.
Fig ure 8.6 • Examination o the recruitment patterns o the vastus medialis oblique.
Mus c le unc tion a nd s tre ngth te s ts Not only knee muscle function and strength has to be assessed but also the muscles of the adjacent joints, for example, the hip and foot. Weakness of hip muscles (e.g. gluteus medius, external rotators, 4 70
Screening o other s tructures ‘in plan’ Screening tests are performed to determine if other movement components contribute to the movement disorder of the knee. It is also necessary to establish whether these components should be included in the treatment. The test procedures mentioned are minimum requirements. If some
P h ys ic a l e xa m in a tio n
of the tests are not impairment free, the movement components need to be examined in more detail. • H ip joint: movement tests should be performed routinely in most movement disorders of a spontaneous onset. Active movements include: exion, in 90° of exion: medial and lateral rotation, extension. Passive tests include: exion/ adduction, including combinations and subsequent reassessment. • Lumbar spine: extension, rotations, quadrant (if possible). PAIVMs, including subsequent reassessment. • Sacroiliac joint: sacroiliac provocation tests such as F/ Ad with compression, Patrick’s test
(FABER test), anterior and posterior tilts, passive accessory movements including subsequent reassessment. (N ote: as F/ Ad with compression is also an important procedure in the examination of hip movement disorders, frequently it is useful to complete the hip examination with the relevant passive tests prior to the screening procedures of the sacroiliac joints.)
• N eurodynamic system: SLR and modi cations (tibial, common peroneal nerve). PKB and slump in side lying, including modi cations (femoral nerve, saphenous nerve, obturator nerve) (see Butler 2000). Box 8.2 describes tests for the nervous system.
Box 8.2 Tests or the nervous system place by releas ing the neck exion (hence reducing neural tens ion) and to as k the patient to report any changes in s ymptoms .
Clinically the nervous s ys tem can be as s es s ed in three ways : neurological examination, neurodynamic tes ts and nerve palpation (Butler 2000). •
•
Neurological exam ination with s ens ory, motor and re ex tes ting is only neces s ary i a peripheral or central nervous s ys tem conduction problem is s us pected. In orthopaedic patients with knee pain a neurological examination is commonly not indicated. Neurodynam ic tests are des igned to tes t the mechanos ens itivity o peripheral nerves and their mobility. For anterior and medial knee pain the neurodynamic tes ts or the emoral and s aphenous nerves are being us ed. For pos terior knee pain the neurodynamic tes ts or the s ciatic nerve and tibial nerve are being per ormed. Lateral knee pain is an indication to tes t the communal peroneal nerve.
Sa p he nous ne rve te s t (Fig. 8.9): • •
Patient and therapist starting position: As in s lump s ide lying. Application of forces: Therapis t extends and abducts the hip o the upper s ide, extends the knee, externally rotates the hip and pos itions the oot in evers ion and plantar exion or evers ion and dors i exion (N. s aphenous can run in ront or behind the exion/extens ion axis o the oot).
Fe mora l ne rve te s t: (Fig. 8.7) • • •
Patient s tarting pos ition: prone, arms bes ide the body. Application o orces : therapis t pas s ively exes the knee. Remark: di erentiation between N. emoralis and quadriceps mus cle is di f cult in this pos ition. There ore this tes t is mos t commonly done in s lump s ide lying (trunk exion and neck exion).
Slump s id e lying (s ee Fig. 8.8) •
The patient is pos itioned in s ide lying, the therapis t brings the leg o the upper s ide into hip extens ion and pas s ively exes the knee. I s ymptoms are reproduced the s tructural di erentiation would take
Fig ure 8.7 • Femoral nerve test.
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Box 8.2—cont’d Sc ia tic ne rve , with e mp ha s is in the tib ia l ne rve (Fig. 8.10)
Sc ia tic ne rve , with e mp ha s is in the c ommuna l p e rone a l ne rve (Fig. 8.11)
• •
• •
• •
•
Patient starting position: Supine, s traight legs . Therapist starting position: The therapis t is s tanding on the s ide o the leg that is tes ted watching towards the patients eet. Localization of forces: the therapis t hands are placed under the toes and on the heel o the patient’s oot. Application of forces: s tarting with dors i exion and evers ion o the oot, ollowed by knee extens ion and hip exion. Knee and/or lower leg s ymptoms may need to be di erentiated by neck exion, trunk or hip movements . Variation: the therapis t f rs t pos itions the leg in SLR and then s he moves the oot in dors i exion and evers ion.
•
•
•
Patient starting position: Supine, s traight legs . Therapist starting position: The therapis t is s tanding on the s ide o the leg that is tes ted watching towards the patient’s eet. Localization of forces: One hand is placed on the dors um and the other hand on the heel o the patient’s oot. Application of forces: s tarting with plantar exion and invers ion o the oot, ollowed by knee extens ion and hip exion. Knee and/or lower leg s ymptoms may need to be di erentiated by neck exion, trunk or hip movements . Variation: the therapis t f rs t pos itions the leg in SLR and then s he moves the oot in plantar exion and invers ion.
Fig ure 8.8 • Slump in side lying.
Fig ure 8.9 • Saphenous nerve test.
Fig ure 8.10 • Sciatic nerve test, with emphasis on the tibial nerve.
Fig ure 8.11 • Sciatic nerve test, with emphasis on the communal peroneal nerve.
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Box 8.2—cont’d A neurodynamic tes t is pos itive i the s ymptoms o the patient are reproduced and altered (increas e or decreas e) with s tructural di erentiation procedures . •
Nerve palpation: tis s ue palpation quality o peripheral nerves and its s urrounding tis s ues , trans vers e gliding and the mechanos enitivity will be as s es s ed with nerve palpation. A prerequis ite or nerve palpation tes ts is the knowledge o the anatomical cours e o the peripheral nerves and that there can be variations . Nerve palpation is pos itive i the s ymptoms o the patient can be reproduced and/or i tis s ue quality di erences during palpation o the peripheral nerves are pres ent. Involvement o peripheral nerves may be s us pected. In cas e o a trauma or operation in his tory and the clinical pres entation o the quality o s ymptoms indicates neurogenic involvement (s ee s ubjective examination). Nerve palpation can be per ormed in neutral and in
any phys iological pos ition, s uch as , or example, unctional demons tration pos itions . Furthermore, nerve palpation may be per ormed in combination with the neurodynamic tes ts . The ollowing s pots are requently palpated: • •
• •
Fem oral nerve: in the groin and along the cours e o the quadriceps (Fig. 8.12). S aphenous nerve: near the knee joint line between the tendons o gracillis and s artorius mus cles (Fig. 8.13). Infrapatellar branches of the saphenous nerve (Fig. 8.14): on the ront o the tibia plateau. Tibial nerve (Fig. 8.15): pos terior in the centre o the knee old. Palpation is eas ier when the nervous s ys tem is pos itioned in s ome tens ion via the hip ( exion) and the oot (dors i exion and evers ion).
Fig ure 8.12 • Palpation o the emoral nerve: in the groin and along the course o the quadriceps.
Fig ure 8.13 • Palpation o the saphenous nerve.
Fig ure 8.14 • Palpation o in rapatellar branches o the saphenous nerve.
Fig ure 8.15 • Palpation o the tibial nerve.
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Box 8.2—cont’d •
Com m unal peroneal nerve (Fig. 8.16): jus t behind the tendon on the M. biceps emoris (the oot is in plantar exion invers ion) and around the collum or head o the f bula.
Fig ure 8.16 • Palpation o the communal peroneal nerve.
Palpation
Swe lling
Te mp e ra ture
Most swellings are best appreciated by inspection, but palpation is necessary to con rm their presence, for example:
Compare the temperature of various areas around the knee with the non-affected side. A decrease in temperature is a sign of autonomic output dysfunction.
E us ion • Place the thumb and index
nger of one hand on either side of the patella. The other hand places the web space over the suprapatellar pouch and squeezes uid distally. A large effusion may be appreciated if the nger and thumb at the side of the patella are separated and a uctuant feeling is produced. • A small effusion may be found with the bulge sign: 1. Fluid is stroked out of the medial gutter next to the patella. 2. The suprapatellar pouch is compressed in the same way as described under (1). 3. Fluid bulges out into the medial gutter as a result of (2). 4. Alternative: step (1), then the lateral gutter of the patella is compressed. 4 74
• A tender swelling of the tibial tubercle may be present in O sgood–Schlatter’s disease • Cyst of the menisci, involving the lateral meniscus, with a tender swelling over the joint line • Prepatellar bursitis: soft tissue swelling anterior to the patella • Chronic synovial thickening: along the suprapatellar pouch with a characteristic doughy sensation when rolled under the ngers; over the medial joint compartment in the gutter at the medial side of the patella, just cephalad of the joint line.
Te nd e rne s s • Tenderness may occur at times in combination with local swelling of ligaments, insertions and muscles (see Fig. 8.17). Positive ndings serve as a comparable sign in reassessment procedures and may indicate the necessity of soft tissue treatment. Tenderness is best palpated in supine with the knee in exion.
P h ys ic a l e xa m in a tio n
• Meniscus injuries may produce tenderness over the anterior, middle or posterior third of the joint line. The points of tenderness may displace if the knee is moved towards extension. • Ligament sprains frequently are tender over the upper and lower attachments. If tender over the joint line, this may be dif cult to distinguish from tenderness stemming from a meniscus lesion. Tenderness or symptom provocation of nerves (e.g. infrapatellar branches of saphenous nerve, tibial nerve, common peroneal nerve).
Pas s ive tes ts Passive tests include physiological and accessory movements. Many of the passive test procedures can be used as therapeutic techniques and, therefore, these test procedures frequently need to be followed by a reassessment of the main physical parameters (‘asterisks’) identi ed so far. The passive tests can be used as physical asterisks in the reassessment procedures if there are comparable signs or symptom reproduction.
Move me nt d ia gra m The establishment of a movement diagram of the most comparable active movements gives more detailed information on the behaviour and interrelationship of pain, resistance and possible motor responses (‘spasm’). Such information may guide the therapist in the determination of treatment techniques by passive movement; additionally the test(s) may be used as physical asterisks in reassessment procedures.
Sta b ility, inte grity a nd me nis c us te s ting
Fig ure 8.17 • Areas o so t tissue lesions o the knee.
In acute lesions with a traumatic onset, stability and meniscus tests may need to be carried out. H owever, it is emphasized that many active and passive test procedures may have already provided indications as to whether lesions in the above-mentioned structures are present. A description of these orthopaedic test procedures may be found in Box 8.3.
Box 8.3 Orthopaedic testing o stability and integrity o ligaments and menisci I indicated, s tability and integrity tes ts are per ormed or the anterior cruciate ligament, pos terior cruciate ligament, medial and lateral collateral ligament , medial and lateral menis cus , anteromedial, anterolateral and pos terolateral ins tability.
Ante rior d ra we r te s t (a nte rior c ruc ia te liga me nt inte grity te s t, p os te rior ob liq ue liga me nt, p os te rome d ia l a nd p os te rola te ra l c a p s ule s , me d ia l c olla te ra l liga me nt, iliotib ia l b a nd ) • •
Patient starting position: In s upine, 90° knee exion. Therapist starting position: Sitting on the edge o the treatment table and s lightly on the patient’s oot to s tabilize it.
• •
•
•
Localization of forces: Therapis t puts the thumbs on the joint line either s ide o the patella tendon. Application of forces: Therapis t pulls the tibia orward. The movement is either per ormed as a s low anterior glide o the tibia on the emur, or a quick jerking movement. Positive result: Exces s ive anterior trans lation (more than 6 mm) or a s o t end- eel compared to the non-a ected knee. Benjamins e et al. (2006) ound in a meta-analys is o 28 s tudies that the s ens itivity o this tes t is 92% (pooled value) and the s pecif city is 91% (pooled value).
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Box 8.3—cont’d La c hma nn’s Te s t (a nte rior c ruc ia te liga me nt inte grity te s t)
•
•
P os te rior d ra we r te s t (p os te rior c ruc ia te liga me nt inte grity te s t, a rc ua te p op lite us c omp le x, p os te rior ob liq ue liga me nt, a nte rior c ruc ia te liga me nt)
• •
•
•
•
Patient starting position: Long s itting or s upine on the treatment table, knee is pos itioned in 15° exion, the oot is res ting on the plinth. Therapist starting position: Standing next to the patient’s leg, acing the patient’s head. Application of forces: Therapis t s tabilizes with one hand the emur and the other hand gras ps the cal , below the knee joint line. The patient mus t relax the hams trings and quadriceps , as they could produce a als e pos itive res ult. Application of forces: Therapis t then initiates a clean orward ‘jerk’ motion o the hand on the cal , to quickly draw the tibia orward. Positive result: Exces s ive anterior trans lation or a s o t end- eel o the anterior trans lation compared to the non-a ected knee. The s ens itivity o this tes t is 85% (pooled rom 28 s tudies ) and the s pecif city 94% (Benjamins e et al. 2006).
P ivot s hi t te s t (a nte rior c ruc ia te liga me nt inte grity te s t) •
•
• •
Patient starting position: Supine or long s itting on a treatment table. The knee is exed to 45°. The limb is s upported by the phys iotherapis t. Localization of forces: Therapis t applies pres s ure to the outer s ur ace o the leg, jus t below the joint line onto the head o the f bula. The other hand s tabilizes the oot while a valgus orce is produced by applying an inward pres s ure through the upper hand. Simultaneous ly, a medial rotation orce is applied to the lower leg as the clinician s lowly extends the knee. Positive result: An obvious ‘s lip’ or a palpable ‘clunk’ at around 10–20° o knee exion. The pooled s ens itivity is 24% and the pooled s pecif city value is 98% (Benjamins e et al. 2006).
P os te rior s a g s ign (p os te rior c ruc ia te liga me nt inte grity s ign, a rc ua te p op lite us c omp le x, p os te rior ob liq ue liga me nt, a nte rior c ruc ia te liga me nt) •
•
•
Patient starting position: Supine, the knee is pos itioned in 90° exion, the oot is res ting on the plinth, hams trings and quadriceps are relaxed. Therapist starting position: Therapis t obs erves the knee rom the lateral as pect or a s tep at the knee joint line. Positive result: A vis ible pos terior s ag o the tibia on the emur.
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• •
• •
The s ens itivity o this tes t is 79% and the s pecif city 100% (Malanga et al. 2003).
Therapist and patient starting position: In the s ame pos ition as or the anterior drawer tes t. Localization of forces: One hand o the therapis t is s tabilizing the tibia and the other hand is applying an anterior pos terior glide to the tibia jus t below the joint line. Positive result: An increas ed glide o the tibia pos teriorly compared to the non-a ected knee. The s ens itivity o this tes t is 51–100% and the s pecif city 99% (in one s tudy) (Malanga et al. 2003).
Qua d ric e p s a c tive te s t (p os te rior c ruc ia te liga me nt inte grity te s t a nd p os te rior joint c omp le x) • •
• •
Patient starting position: Supine with the knee in 80–90° o exion, the oot res ting at on the plinth. Therapist starting position: Therapis t is obs erving the a ected knee or an anterior trans lation o the tibia rom a lateral view while the patient contracts the thigh mus cles . Positive result: I the tibia trans lates more than 2 mm. The s ens itivity o this tes t ranges between 54–98% and the s pecif city rom 97–100% (Malanga et al. 2003).
Ab d uc tion (va lgus ) s tre s s te s t (me d ia l c olla te ra l liga me nt) • • •
•
Patient starting position: Supine lying on a treatment table. Therapist starting position: At s ide o patient’s leg, acing patient’s head. Application of forces: Therapis t applies a valgus orce to the knee in 20–30° exion compared to 0° extens ion. Positive result: • At 20° pain over the medial joint line – mild injury to the medial collateral ligament; • At 20° pain over the medial joint line and s ome laxity – partly intact medial collateral ligament; • 20° pain and gros s ins tability – complete rupture o the medial collateral ligament and involvement o the pos terior oblique ligament, pos terior cruciate ligament, pos teromedial caps ule; • 0° – any ins tability in this pos ition s ugges ts that there may be a medial collateral ligament tear,
P h ys ic a l e xa m in a tio n
Box 8.3—cont’d
•
anterior cruciate ligament, medial quadriceps expans ion, s emimembranos us mus cle, pos terior oblique ligament, pos terior cruciate ligament, pos teromedial caps ule) . The s ens itivity o this tes t is 86–96% and the s pecif city is not reported (Malanga et al. 2003).
Mc Murra y’s te s t (inte grity te s t o me nis c i) •
•
Ad d uc tion (va rus ) s tre s s te s t •
•
•
Like the medial collateral ligament s tres s tes t but the therapis t applies a varus orce to the knee in 20–30° compared to 0° extens ion. Positive result: • At 20° pain over the lateral joint line with no laxity – mild injury o the lateral collateral ligament • At 20° pain over the lateral joint line and s ome laxity – moderate injury with partly intact lateral collateral ligament; • At 20° pain over the lateral joint line and gros s ins tability – may s ugges t a complete rupture o the lateral collateral ligament, arcuate popliteus complex, pos terolateral caps ule, iliotibial band, biceps emoris tendon) • 0° – any ins tability in this pos ition s ugges ts that there may be a lateral collateral ligament tear, cruciate ligament, lateral gas trocnemius , iliotibial band or biceps emoris tendon involvement. The s ens itivity o this tes t is 25% and the s pecif city is not reported (Malanga et al. 2003).
P a s s ive te s t move me nts o the va rious kne e c omp one nts
•
Patient starting position: The patient is lying s upine on the plinth with the knee ully exed. Laterally rotate the tibia and pas s ively extend to 90° whils t palpating joint line. Positive result: An audible ‘click’ or ‘pop’ with reported pain on the medial s ide may s ugges t a tear o the medial. The s ens itivity o this tes t was reported to range rom 10–66% (Scholten et al. 2003) and the s pecif city 57–98% (Malanga et al. 2003 and Scholten et al. 2003).
Ap p le y’s grind te s t (inte grity te s t o me nis c i) •
•
•
Patient starting position: The patient is lying prone with the knee 90° exed. The therapis t applies traction to the knee joint and then adds medial and lateral rotation. Secondly, s he applies compres s ion combined with medial and lateral rotation. Positive result: Pain reported during the application o compres s ion in combination with rotation may s ugges t a menis cal injury; dis traction pain may s ugges t ligamentous s train. The s ens itivity o this tes t ranges rom 13–58% and the s pecif city 80–99% (Malanga et al. 2003, Scholten et al. 2003).
○ extension/ abduction, including
anteroposterior movement (see Fig. 8.4B).
Physiological movements may include:
The end-feel may be appreciated in two different ways, i.e. with the knee fully extended and relaxed or passively ex the knee approximately 20° than allow it to drop back into full extension. A normal knee can fall into full extension with a typical painless hard end-feel. In patients with osteoarthritis a similar end-feel may be found, but the joint lacks full extension. A meniscus lesion may produce a softer end-feel and the leg may bounce slightly more once dropped from exion to extension.
• Extension variations:
• Flexion variations:
As described previously, in some cases the test procedures may need to be performed under compression. Many of the passive test procedures can also be used as therapeutic techniques and therefore these test procedures frequently need to be followed by a reassessment of the main physical parameters (‘asterisks’) identi ed so far.
Tibio emoral joint
○ ○ ○ ○
extension (see Fig. 8.1A) extension/ adduction (Fig. 8.18A) extension/ abduction (Fig. 8.18B) extension/ adduction, including anteroposterior movement (see Fig. 8.1B)
○ exion (see Fig. 8.2) ○ exion/ adduction, including rotations (see ○
Fig. 8.5B) exion/ abduction, including rotations (see Fig. 8.5A)
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A
B
Fig ure 8.18 • Tibio emoral movements in extension: A extension/adduction; B extension/abduction.
○ medial rotation, lateral rotation (see Figs 8.3,
8.32) (may also be carried out as accessory movements). • Accessory movements may include: ○ abduction, adduction ○ posteroanterior movement, anteroposterior movement ○ longitudinal caudad, longitudinal cephalad ○ transverse medially, transverse laterally ○ medial rotation, lateral rotation. • The accessory movements are most frequently applied to the tibia; however, they can be carried out on the femur as well.
A detailed description of the examination and treatment techniques may be found on pages 487–496.
• transverse movement medially and laterally, including inclinations (see Fig. 8.39) • distraction (Fig. 8.20) • compression (Fig. 8.21) • rotation around the sagittal axis (Fig. 8.22) and around the longitudinal axis. The examination (and treatment) procedures frequently need to be carried out in various positions
A
D
• longitudinal movement caudad and cephalad, including inclinations (see Fig. 8.40) 4 78
caud ceph med lat
C
Patello emoral joint The patellofemoral joint needs to be examined with accessory movements which may include (Fig. 8.19):
A B C D
E B G
F Rotation
Distraction
Fig ure 8.19 • Accessory movements o the patella.
P h ys ic a l e xa m in a tio n
A
Fig ure 8.21 • Patello emoral compression.
B
Fig ure 8.20 • Patello emoral movements: A distraction; B distraction – alternative. Fig ure 8.22 • Patello emoral rotation (sagittal axis).
of exion or exion/ abduction. Furthermore, it may be necessary to add a certain degree of compression to the movements and in some cases movements may need to be performed in weight-bearing positions (see Fig. 8.41). A detailed description of examination and treatment techniques may be found on pages 498–502. C repitus is best appreciated by palpating the patellofemoral joint while exing and extending the knee. A ne crepitus may be present in chondromalacia of the patella (sensation of ne sand or glass) whereas a coarse crepitus (sensation of ‘dry wood’) may indicate osteoarthritis. If the crepitus occurs in combination with pain, it is an important comparable sign which has to be assessed during the application of treatment and in reassessment procedures.
Clinical tip: I during the application o pas s ive movement the crepitus s eems to become les s , immediate reas s es s ment o the main tes t procedures may s how benef cial changes .
In certain cases of recurrent subluxation of the patella, lateral movement of the patella may provoke pain. The patient may then become acutely aware that the patella is about to dislocate and any further attempts to move the patella are actively resisted by contractions of the quadriceps, i.e. apprehension. 4 79
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Superior tibiof bular joint The superior tibio bular joint is often forgotten when seeking the source of lateral leg and knee pain. Although not a frequent cause of pain, it is suf ciently common to warrant inclusion in routine examination. A detailed description of the examination and treatment techniques may be found on pages 502–504.
• The joint needs to be examined with accessory movements. • Test (and treatment) procedures may need to be carried out in various foot positions and
different positions of knee exion. Additionally, it may be necessary to add compression to the test and treatment procedures. • Frequently these procedures with their different positions are easiest to perform in side lying, with the affected leg above and the tibia well supported by the plinth in front of the unaffected leg. Examination and treatment of the superior tibio bular joint may include:
• Anteroposterior movement (Fig. 8.23) • Posteroanterior movement (Fig. 8.24)
A B
Fig ure 8.23 • Superior tibio bular joint: A anteroposterior movement; B anteroposterior movement with compression.
A
Fig ure 8.24 • Superior tibio bular joint: A posteroanterior movement; B posteroanterior movement with compression. 480
B
Tre a tm e n t
A
B
Fig ure 8.25 • Superior tibio bular joint:B longitudinal movement with lever o oot; B longitudinal movement applied locally to head o the bula.
• Longitudinal movement caudad (Fig. 8.25) • Longitudinal movement cephalad (may be carried out with the lever of the foot or directly to the head of the bula) • Compression • Rotary movements (with the lever of the foot).
Tre atme nt In clinical practice, manipulative physiotherapists have established competencies and skills to deal with impairments of segmental mobility (arthrogenic), motor control and postural stability (myogenic) and nerve mechanosensitivity. Physiotherapists should design individualized treatment programmes, collaboratively with the patient, based on the contemporary scope of practice, including an understanding
of contextual mediators of the pain and disability and a comprehension of whether they would be modi able or not. All impairment-oriented treatments should follow up with an emphasis on restoring functional capacity, and guiding patients in the transition from health care needs to healthy lifestyles and healthy living. Passive mobilization may play a central role in the treatment of many movement disorders of the knee; however, treatment often needs to be complemented with automobilization, exercises to regain motor control over movement patterns, restoration of proprioceptive feedback, normalization of gait patterns and guidance to the full level of activities needed in daily life, as well as a towards an active lifestyle to maintain healthy movement behaviours. Integrated approaches may include passive mobilizations of the patellofemoral or tibiofemoral joint combined with soft tissue techniques or neurodynamic treatment technique. Comprehensive strategies for motor control of the knee and lower extremity are widely available in companion texts and supporting references (Sahrmann et al. (2011). To Maitland, the selection and application of treatment was an art, in which it was essential to know ‘when to apply, which technique and in which form’ (Maitland 1986). This viewpoint was meant as a counterpoint to the almost automatic selection of treatment techniques, based on biomechanical theoretical rules. Treatment techniques should be considered within the overall context of the disabilities of the patient and local impairments such as symptom behaviour, motor reactions (‘spasm’) and perceived resistance to the movement. Techniques have to be adapted at all times to the changes in symptoms and signs of the relevant movement impairments. The section below describes the selection and progression of treatment with passive mobilization, based on the information gained during subjective examination, and active as well as passive movement tests.
Selection The passive movement techniques from which a selection can be made in the treatment of movement disorders of peripheral joints are as follows: 1. The physiological movements: • Flexion and extension • Rotation 481
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2. The localized accessory movements, which can be produced by direct pressure being applied to the tibia or femur as part of the tibiofemoral joint, or to the patella and the bula as part of the superior tibio bular joint. The directions of the pressures that produce these accessory movements are: • Tibia and/ or femur: posteroanterior, anteroposterior, transverse lateral, transverse medial, medial shaft rotation, lateral shaft rotation, longitudinal caudad and cephalad movements. • Patella: longitudinal caudad and cephalad, transverse lateral, transverse medial, medial rotation, lateral rotation movements, as well as distraction and medial and lateral ‘shelling’ • Fibula: mainly posteroanterior and anteroposterior, longitudinal caudad and cephalad movements. The directions of the above pressures can be varied by inclining them medially, laterally, cephalad and caudad, and also by minimally varying the points of contact. 3. Passive mobilizations in combination with active movements (see also Chapter 5). All of the above movements can be used in different grades and rhythms, and they can be combined in many varied sequences, often related to the patient’s functional demonstration or injuring movement. The movements can be used to treat four groups of presentation as follows: 1. 2. 3. 4.
Pain Stiffness Pain associated with stiffness Momentary jabs of pain.
These groupings parallel those in Maitland (1986). Since the severity of referred symptoms can vary so widely, it is useful when selecting techniques if the selection is initially related to the two extremes of severity. The rst extreme to be described will be the pain-limiting movement at the beginning of range of the ‘pain-throughrange’ situation (group 1), where pain is severe and inhibits the patient’s movements – there is no stiffness or muscle spasm limiting movement. The other extreme is where the patient complains of stiffness, not pain, although pain is provoked when the stiff movements are stretched (group 2). This is the end-of-range situation, where pain is minimal. 482
Group 1 – pain G roup 1 patients have severe pain-limiting movement, rather than it being limited by any other factors. The techniques that can be used are as follows.
Ac c e s s ory move me nts in a p a rt o the ra nge tha t is tota lly re e o a ny p a in or d is c om ort The joint to be treated must be positioned in a totally symptom-free position. The amplitude of the movement should be the largest possible amplitude that can be achieved painlessly. To make the amplitude large, it may be necessary to start from a point well back in the range. The rhythm of the movement must be smooth and slow. As the patient’s symptoms improve, so the treatment movement can be moved further into the range and the position of the patient’s knee may be carefully changed towards the painful restriction. The technique may also be advanced to a stage where the large amplitude movement is taken into a degree of discomfort.
P hys iologic a l move me nts When physiological movements are used to treat pain, they too must be performed without provoking pain or discomfort. As with the accessory movements, the joint being treated must be positioned painlessly in a mid-position for the main directions of movement; for example, in the case of the knee, this would be the mid-position of exion and extension. The treatment with the physiological movement should be in the most painless direction, and the large, slow, smooth amplitude must end before the onset of any discomfort. As the patient’s symptoms and movement signs improve, so the treatment movement can be taken further into the range and the amplitude of the movement thereby increased. A later progression, as mentioned above, is that the movement can be taken into a controlled degree of discomfort. The duration of the application of a treatment technique depends mainly on the ‘assessment while performing the technique’. During the application of the technique the therapist should monitor any changes in pain, discomfort, resistance and motor reactions. If the changes are favourabe, the technique can be continued. If undesired effects (for
Tre a tm e n t
example, discomfort) occur, the technique should be stopped and the effects of the treatment need to be reassessed. In the next session often the rst sign of progression is that the technique being used may be performed for a longer period without provoking any of the undesired effects.
the remainder, and if all are stretched equally strongly the primary accessory movement will not only be less ‘giving’ but will also cause greater discomfort.
Group 2 – s ti nes s
H aving discussed the two extremes of presentation – all pain and no stiffness, and all stiffness and no pain – we now come to the third group of patients, where pain and stiffness occur together. This is the largest group and the most challenging to treat. These patients will have pain, either as a constant symptom or as a pain on movement. In both examples the movements will have an element of stiffness. O n examining the movements, there will be a relationship between the point of onset of the pain in the range and the limit of the available range. There should be a ‘matching’ comparison between the symptoms of which the patient complains and the ndings on examining his knee movements. Patients having constant symptoms will have pain com mencing early in a range of movement, and the pain will continue and increase until the limit of the range is reached (i.e. a ‘pain-through-range’ situation). With the majority of disorders that cause a patient to have pain only on movement, he will have this pain provoked at the end of the available range of an appropriate movement (i.e. an end-of-range-pain situation). In addition to the patient having through-range pain or end-of-range pain, there is another feature to be clari ed. With the patient who worsens with pain at the end of range, it is necessary to determine whether the restriction of the movement is the dominant factor or whether pain is more dominant. The use of the movement diagram (see Appendix 1) explains this clearly. When pain is the dominant factor, P1 will start before R1 and even if it is R2 that limits movement, P′ (‘P prime’, prime being an engineering and mathematical term) will be very high on the R2L vertical line above L. When stiffness is the dominant element, P 1 may start before R1 , after R1, or at the same point in the range as R1, but R2 will be the factor that limits the available range, while P′ will be at any level on the R2L vertical line above L, well below R2. H owever, the more dominant the stiffness factor, the lower P′ will be on the R2L vertical line.
G roup 2 refers to patients who seek treatment because stiffness limits normal function or because a stiff joint is slightly painful when stretched strongly. They are not seeking treatment because of severe pain, but because they have dif culty in squatting or extending the knee fully. There are many other similar circumstances. When the therapist is examining the patient’s movements, all movements are restricted. When these movements are stretched, they are either pain-free or minimally painful. When selecting the techniques to treat the above problems, the therapist should use two kinds of stretching movements and alternate them. After selection of the primary movement needing to be stretched (e.g. extension of the knee), the rst kind of movement is the physiological movement of extension or extension-abduction or extensionabduction as an oscillatory stretching movement at the limit of the range. This should be performed for approximately a minute or so, varying between strong and gentler strengths, while monitoring the possible changes in pain, light discomfort and protective motor respeonses. The second kind of movement involves accessory movements (again stretching and oscillatory movements of varying strengths) while the knee joint is positioned at the limit of the range of extension. All directions of accessory movement should be utilized. Following the accessory movements, the physiological extension technique is repeated. And so the routine continues, alternating accessory movements at the limit of the physiological range with the primary physiological movement. The same principles can be used in conjunction with any primary physiological movement. Sometimes a patient may have a restricted range of movement, where the restriction is caused by one particular accessory movement rather than the physiological movement itself. This is determined during the examination when the ranges of accessory movements are assessed at the limit of the stiff movement. O n such examination, the particular accessory movement will be found to be stiffer than
Group 3 – pain with s ti nes s
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When pain is by far the more dominant element, the choice of techniques will be identical with that already described above for ‘pain’ (group 1). When stiffness and pain are equally dominant, it is important for the less experienced practitioners always to limit the initial techniques to those already described for treating ‘pain’. It is only when these fail to improve the patient’s symptoms or his test movements that using techniques for treating stiffness should be considered. When stiffness is by far the more dominant element, the technique will be the same as has been described above for ‘stiffness’. The only differences will be the following: 1. Initially only the accessory or physiological movements will be used (not both), either because the amount of treatment should be limited at the beginning or so as to make assessment of the value of the relative techniques more effective. 2. It is necessary to decide whether the most painful and restricted (i.e. primary) accessory movements near (not at) the limit of the primary physiological range should be selected or whether the most painful and restricted (i.e. primary) physiological movement should be selected. 3. The rmness and rhythm of the techniques may need to be modi ed in response to respecting the discomfort felt during the technique. The discomfort felt during the performing of the technique at a constant rhythm and position in the range should lessen or at least remain unchanged; it must not be allowed to continue worsening. 4. Initially, a stretching technique should not reproduce a patient’s referred pain. Clinical experience shows that some structures that have been sprained or strained need, at some stage, to be hurt in a controlled manner to set the healing processes in motion. Perhaps this fact bears some relationship to the mechanical measures resorted to in order to stimulate union in un-uniting fractures. When such a technique is being performed, the patient will often spontaneously say, ‘It’s hurting but it’s a nice hurt’. Such a comment nearly always means that the right choice of technique has been made, but proof lies in the assessment. O ther painful disorders decidedly ‘object’ to being hurt. If the rst steps in selection are to choose techniques for treating ‘pain’ described earlier, and to progress to treating pain only by using a technique that provokes pain 484
as described above, no wrong steps will be taken. There is no method of determining whether the patient’s disorder requires to be hurt to make it heal, other than to use the technique provoking minimal discomfort for a very brief time and then to assess its effect over 24 hours. Therefore, this means that when rst using a technique that provokes local pain: 1. The discomfort must be kept to a minimum 2. The technique must be performed slowly and smoothly with the patient totally relaxed 3. During the rst few oscillations of the technique, performed at a constant rhythm and position in the range, the manipulative physiotherapist must know: a. If the hurt is only slight and in rhythm with the technique, in which case the technique is continued for another 10 seconds; if the hurt in rhythm is increasing, STO P. b. If the technique is causing an ache, irrespective of whether it is also causing a hurt in rhythm, STO P. c . That the technique is continued only if the hurt decreases or remains unchanged. 4. The technique is performed only for a maximum of half a minute before reassessing the patient’s symptoms and signs 5. It is important to remember that it is better to do only a little treatment and make use of the 24-hour assessment and nd that nothing has been gained, than it is to do a little too much and nd later the patient was much worse half an hour after treatment. It is the 24-hour period that is the most informative and useful of the types of assessment.
Group 4 – momentary pain This patient experiences his pain as a sudden momentary jab, which occurs unexpectedly. It is always associated with movement, although the movement may be so minimal that the patient is not aware that there has been a movement. The selection of technique under these circumstances is entirely dependent upon the examination de ning the movement(s) that provoke this pain. The movement is usually a physiological movement and position, which includes accessory movements.
Tre a tm e n t
The treatment technique selected is the accessory movement in the combined position that reproduces the ‘momentary pain’. The technique is nearly always quite a strong grade IV movement followed by gentle grade III movements to relieve any treatment soreness.
• If, for example, exion is very restricted, both the tibiofemoral joint and the patellofemoral joint need to be treated while holding the leg at the end of the limited range.
P a te llo e mora l joint
When the knee is very painful, worse when walking or with the rst few steps following rest, the treatment techniques are directed towards treating pain (group 1). Although all accessory movements may be considered, frequently rotary movements may be the most successful as an initial treatment.
The treatment of patellofemoral disorders calls for a high degree of skill and considerable delicacy. When patellofemoral movement is painful, the initial session(s) need to be carried out extremely gently. It is far better to perform movements too gently and for too short a time than to nd out at the following session that they had been performed too excessively, even to the smallest degree.
• The knee may be positioned comfortably in a
• O scillatory distraction may be the rst choice
neutral, pain-free position on an easily moulded pillow. The therapist palpates the joint line with one hand and the other hand grasps around the malleoli and performs the rotation movements of the tibiofemoral joint with the latter hand. • For minor symptoms, extension/ abduction, extension/ adduction, exion/ adduction and exion/ abduction may be used in treatment. • If movements are very restricted but provoke only minor symptoms, physiological movements (e.g. extension or exion combinations in abduction and adduction) need to be taken into consideration.
for treatment if any other movement of the patella seems to be too vigorous for the current condition of the patient. A slow progression of treatment can take place once it is established how the patient reacts to this gentle treatment. • O n the other hand, there are times when maximum amplitude movement should be performed in one or more directions, at the same time maintaining a strong compressive force on the patella. See Box 8.4 for the use of passive movement with compression). • If, for example, it is found that the patient is able to squat fully without pain and all
Tib io e mora l joint
Box 8.4 The use o passive movement with compression in examination and treatment One o the original contributions o Maitland to the world o manipulative phys iotherapy is the treatment o joint s ur aces with pas s ive mobilization, while holding the joint s ur aces under a certain amount o compres s ion (Maitland 1980, 1985). Indications or the examination o movements o a s ynovial joint with its s ur aces compres s ed together include:
•
•
•
•
When the in ormation o the s ubjective examination s ugges ts the pres ence o a joint s ur ace dis order (e.g. in the knee: particular problems with the patello emoral joint while s quatting down, or walking on s tairs in the weight bearing phas e in the cas e o tibio emoral movement dis orders ) When the his tory indicates that the injuring activity includes joint loading
•
•
•
Reproducing the patient’s s ymptoms when other tes t movements have ailed to do s o When through-range-pain is pres ent and the pain res pons e is greater when compres s ion is added, there ore conf rming the pres ence o joint s ur acerelated problems As s es s ing any changes in the riction- ree eel to joint movement when compres s ion is added Determining the mos t appropriate technique to progres s the treatment o a joint s ur ace dis order Exploring the mos t com ortable means o treating a very pain ul periarticular dis order (Maitland 1991).
Compres s ion can be applied to any s ynovial or non-s ynovial joint. In the knee complex the techniques
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Box 8.4—cont’d may be applied to the tibio emoral joint and to the patello emoral joint. Examples o compres s ion applied to the patello emoral joint (Figs 8.26–8.29): •
•
Patient starting position: The tibio emoral joint s hould be pos itioned in extens ion and als o in di erent pos itions o exion. The reas on or this is that in di erent pos itions o tibio emoral exion the unders ur ace o the patella will have di erent points o contact with the emoral condyles . Therapist starting position: Standing by the s ide o the couch acing acros s the patient’s body
Fig ure 8.26 • Cephalad movement with compression with the knee extended.
Fig ure 8.28 • Caudad movement with compression with the knee f exed.
486
•
•
Localization of forces: One hand s hould cup around the patella in order to direct the movement. The other hand s hould be placed s o that the heel o the hand is in contact with the margin o the patella at a point relevant to the direction o movement required. When compres s ion is required the hand which is cupped around the patella is us ed to apply pres s ure through its anterior s ur ace while the other hand moves the patella. The examiner’s elbows s hould be pos itioned in line with the movement direction to be per ormed Application of forces: The patella s hould be moved cephalad, caudad, medially, laterally and in a direction o axial rotation (es pecially with the medial border o the patella moving anteropos teriorly into the emoral intercondylar area). The f ndings
Fig ure 8.27 • Caudad movement with compression with the knee extended.
Fig ure 8.29 • Cephalad movement with compression with the knee f exed.
Tre a tm e n t
Box 8.4—cont’d regarding s moothnes s o movement and pain res pons e s hould be compared with the patient’s complaint and the normal knee • Application in treatm ent: Patello emoral dis orders which are mechanical or degenerative in origin res pond well to treatment by pas s ive movement and a degree o compres s ion which permits movement without pain or with only a s mall amount o dis com ort. The technique is per ormed as des cribed above and the movement is os cillated or one–two minutes while monitoring the change in s ymptoms , the behaviour o crepitus and through-range s moothnes s o s ynovial uid (s ee examination o the patello emoral joint on pages 478–479). As s es s ment o changes e ected is then carried out and the degree o compres s ion us ed in treatment is bas ed on the as s es s ed res pons e. A s tage may be reached where s trong compres s ion is us ed without increas e in dis com ort. The patient s hould by then notice improvements in both s ymptoms and unction. At times it may be neces s ary to us e unctional weight-bearing pos itions in which the techniques under compres s ion are being applied (Fig. 8.30, s ee als o Fig. 8.41C). Numerous publications des cribe how s tatic and dynamic loading may have benef cial e ects on joint s ur aces . Mechanical loading o articular cartilage s timulates the metabolis m o res ident chondrocytes and induces the s ynthes is o molecules to maintain the integrity o the cartilage. Mechanical s ignals modulate biochemical activity and changes in cell behaviour through mechanotrans duction. Compres s ion o cartilage res ults in complex changes within the tis s ue including matrix and cell de ormation, hydros tatic and os motic pres s ure, uid ow, altered matrix water content, ion concentration and f xed charge dens ity. Thes e changes are detected by mechanoreceptors on the cell s ur ace, which include mechanos ens itive ion channels and integrins that on activation initiate intra-cellular s ignalling cas cades leading to tis s ue remodelling. Exces s ive mechanical loading als o in uences chondrocyte metabolis m but unlike phys iological s timulation leads to a quantitative imbalance between anabolic and catabolic activity res ulting in depletion o matrix components (Ramage et al. 2009). However, there does not s eem to be s u f cient res earch available to underpin the clinical notion that ‘loading’ the s tructures (meaning moving the joints
examination tests have revealed only minimal signs, it may be necessary to move the patella quite forcibly while the tibiofemoral joint is exed approximately 40° and compression applied by the physiotherapist’s hand.
Fig ure 8.30 • Mobilization o the tibio emoral joint in weight-bearing position.
pas s ively while gently holding the joint s ur aces compres s ed) leads to better clinical outcomes than jus t making repeated loading and dis traction movements . In the rehabilitation a ter cartilage repair controlled loading s hould occur through range o motion, with s u f cient res t periods between loading s es s ions in the early rehabilitation phas es . It has been des cribed that gentle graduated weight bearing s hould be included and it appears that dynamic loading is better than s tatic loading and longer low-intens ity exercis e is better than s horter high-intens ity exercis e (Lundon & Walker 2007). It has been des cribed that s tatic and os cillatory mechanical compres s ion and os cillatory tis s ue s hear can enhance or inhibit extracellular matrix s ynthes is and gene expres s ion in chondrocytes (Leipzig & Athanas iou 2005). Application o os cillatory tens ion in a f brin cons truct culture s ys tem in uenced proli eration and matrix production in both chondrocyte and f brochondrocyte s ynthes is (Vanderploeg et al. 2004). Gentle pas s ive movements with the joint s ur aces compres s ed together, while monitoring the s ymptom res pons es o the patient may be cons idered within this context, s uch as a gradual increas e o the loading o the joint s tructures . However, urther res earch is needed to underpin this clinical obs ervation.
• Next to passive mobilizations of the patella, it has been stated that rehabilitation of muscular control should take place as early as possible to allow optimum tracking of the patella in the femoral groove during the rst 20–30° of 487
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exion. In particular, the recruitment of the vastus medialis oblique in relation to the vastus lateralis within the overall muscular chain of the foot and pelvis merits special attention. Corrective tape may be applied to the patella if movements would be too painful to start in an early phase (H ilyard 1990, McConnell 1996).
Sup e rior tib iof b ula r joint O ften it may not be easy to determine whether the superior tibio bular joint is responsible for a patient’s symptoms. Frequently this needs be ascertained by performing stronger techniques with compression and comparing these with the unaffected leg.
• When a comparable sign is found this
Fig ure 8.31 • Extension o the tibia on the emur.
movement should be used in treatment. • Initially it should be performed rmly but not vigorously. • Posteroanterior and anteroposterior movements can be performed. In the progression of treatment they may be carried out under rm compression. H owever, it needs to be emphasized that if symptoms are being produced during the treatment technique, they should occur in the rhythm of the movement and they should settle fairly quickly once the treatment has stopped. • When the superior tibio bular joint is responsible for symptoms, frequently it responds very readily and rapidly to massive mobilizing techniques.
• Therapist starting position: Standing by the
In the following section passive physiological and accessory movements of the tibiofemoral, patellofemoral and superior tibio bular joint are described.
• The lower leg is moved through a range of
De s c riptio n o f te c hnique s Phys iological movements o the tibio emoral joint: examination and treatment techniques Exte ns ion (Fig. 8.31) • Direction: Extension of the tibia on the femur. • Symbol: E. • Patient starting position: Supine, lying in the middle of the couch. 488
patient’s right thigh facing the feet, kneeling on own left shin to support under the lower end of the patient’s femur with the left thigh. When the patient’s knee is exed, the therapist’s left thigh also moves to the patient’s calf.
Localization o orces (position o therapist’s hands) • Both hands hold distally around the patient’s lower leg from behind. • The left elbow is placed by the side of the patient’s knee so that the axis of the therapist’s left arm coincides with the axis of the knee movement.
Application o orces by therapist (method) 25–30° by the therapist lowering and raising the patient’s leg through an arc of movement. The therapist’s arms are used to achieve this.
Variations in the application o orces • Adduction and abduction can be added to this movement as required. This will require rm but comfortable control of femoral rotation with the insides of both elbows and distal parts of the upper arms. • Alternatively, perform extension as described below in extension/ abduction and extension/ adduction.
Uses • Most useful as a grade III movement. • For through-range pain and stiffness, especially in OA.
De s c rip tio n o f te c h n iq u e s
• To help recovery of range after injury,
• The left forearm is directed at right angles to
immobilization or disuse.
Exte ns ion/a b d uc tion, e xte ns ion/ a d d uc tion (e xte ns ion) (see Fig. 8.18) An example o this concept’s approach Some manipulative therapist authors argue the axiom that all examination and treatment passive movements must be performed in the directions (roll, spin, slide) in which they occur actively. This is anathema to the concept propounded in this book: in fact, the Maitland Concept says the opposite, on the basis of the very positive importance of the ‘pain provoked with movement’ principle. The ‘comparable’, ‘appropriate’ pain response is nearly always found with the non-physiological rather than the physiological movement.
• Direction: Extension/ abduction, extension/ adduction (and extension) of the tibiofemoral joint. • Symbols: E/ Ab, E/ Ad (E). • Patient starting position: Supine, lying in the middle of the couch. • Therapist starting position:
○ For grades III and IV (see Fig. 8.18):
○
standing by the patient’s right ankle facing the left hip; the therapist’s right knee and lower leg rest on the couch at right angles to the patient’s leg; the patient’s heel is supported across the therapist’s thigh adjacent to the ASIS. For grades IV and IV+ (see Figs 8.1, 8.4): standing by the patient’s right knee.
the shaft of the femur and tibia so that the abduction component can be produced.
G r a d es III a nd IV – E/ Ad • The left hand supports the patient’s knee • • •
• • •
laterally around the lateral aspect of the joint. The ngers of the left hand reach the lateral condyle of the tibia posterolaterally. The thenar eminence is anterolateral. The heel of the right hand is placed: (1) over the medial epicondyle of the femur; (2) on the medial condyle of the tibia; (3) over the joint line medially. The ngers of the right hand reach posteriorly. The thenar eminence of the right hand is placed slightly anteriorly. The right forearm is directed at right angles to the shaft of the femur and tibia so that the adduction component can be produced.
G r a d es IV a nd IV+ – E/ Ab (see Figs 8.1, 8.4) • With the patient’s leg medially rotated. • The right hand holds under the patient’s heel from the lateral side. • The left hand is placed anterolaterally: (1) on the femur; (2) on the tibia; (3) on the joint line.
G r a d es IV a nd IV+ – E/ Ad (see Figs 8.1, 8.4) • With the patient’s leg laterally rotated. • The right hand holds under the patient’s heel from the medial side. • The left hand is placed anteromedially: (1) on the femur; (2) on the tibia; (3) on the joint line.
Localization o orces (position o therapist’s hands)
Application o orces by therapist (method)
G r a d es III a nd IV – E/ Ab • The right hand supports the patient’s knee
G r a d es III a nd IV – E/ Ab • The patient’s knee is raised and lowered
• • •
• •
medially around the medial aspect of the joint. The ngers reach the medial condyle of the tibia posteromedially. The thenar eminence is anteromedial. The heel of the left hand is placed: (1) over the lateral epicondyle of the femur; (2) on the lateral condyle of the tibia; (3) over the joint line laterally. The ngers of the left hand reach posteriorly. The thenar eminence of the left hand is placed slightly anterior.
through a distance of approximately 13–15 cm by the therapist’s hands. • A constant pressure is maintained against the lateral surface of the patient’s knee by the heel of the left hand placed in one of three positions as described above. • Each of the three positions will produce a different movement of the tibiofemoral joint: 1. When the heel of the left hand is against the femur with a strong abduction force (abduction of the tibial shaft), the femur will 489
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tend to move slightly medially on the tibia during extension/ abduction 2. When the heel of the left hand is against the tibia, the tibia will tend to move medially on the femur during the extension/ abduction movement 3. When the heel of the left hand is over the joint line the whole movement will simply be extension/ abduction.
• Note that the stronger the abduction pressure required the more the therapist needs to crouch over to bring the left shoulder closer to the patient’s knee.
G r a d es III a nd IV – E/ Ad • The same application of forces applies to extension/ adduction as for extension/ abduction with the exception that the left hand becomes the right hand, the medial movement of the tibia and femur becomes lateral movement, extension/ abduction becomes extension/ adduction, abduction becomes adduction, and the left shoulder becomes the right shoulder.
G r a d es IV a nd IV+ – E/ Ab • With the patient’s leg medially rotated, support under the patient’s heel and contact against the anterolateral aspect of the knee (with left elbow only slightly exed), the therapist’s trunk is rotated to the left and back again to produce the small oscillatory movements in the direction of extension/ abduction.
G r a d es IV a nd IV+ – E/ Ad • With the patient’s leg laterally rotated, support under the patient’s heel and contact against the anteromedial aspect of the knee (with the left elbow straight), the therapist’s trunk is side exed to the left and back again to produce the small oscillatory movements in the direction of extension/ adduction.
Variations in the application o orces: extension (E) • The above methods can be adjusted so that movement of the tibiofemoral joint is produced into extension only. • For grade III, for example, the left hand is placed laterally around the joint and the right hand is placed medially around the joint during the movement of raising and lowering the knee. In this way the movement will be into tibiofemoral extension only. 490
• For grade IV, the patient’s leg is not rotated for convenience, the right hand supports the heel and the left hand is placed either directly anterior on the femur, anteriorly over the joint line (around the patella) or anteriorly on the tibial tubercle. In this way with the hand on the upper leg, the femur will move anteroposteriorly in relation to the tibia. With the hand over the joint line the tibiofemoral joint movement will be extension only and with the hand on the tibia, the tibia will move anteroposteriorly in relation to the femur during extension.
Uses • As special examination tests when knee symptoms are minimal and there is a full painless range of exion and extension. • As functional corners to be examined and treated to ensure the joint regains its ideal movement capacity after injury or disuse. • As excluding or screening tests for the knee. • To con rm ligamentous injury or internal mechanical derangement.
Fle xion/a b d uc tion, e xion/a d d uc tion (see Fig. 8.5) • Direction: Abduction or adduction of the tibia on the femur at the limit of full exion of the knee. • Symbols: F/ Ab, F/ Ad. • Patient starting position: Supine, lying at the edge of the couch with the hip exed to 90° or beyond, and the knee fully exed (see Fig. 8.2). • Therapist starting position: Standing beside the patient’s right knee facing the patient’s head.
Localization o orces (position o therapist’s hands) • The left hand supports the patient’s thigh. • The right hand grasps anteriorly around the patient’s ankle.
For F/ Ab • The ngers of the right hand push laterally against the medial surface of the patient’s calcaneum posteriorly. • The right thumb is hooked around the patient’s lateral malleolus.
De s c rip tio n o f te c h n iq u e s
For F/ Ad • The ngers of the right hand hook around the patient’s medial malleolus. • The thumb and metacarpophalangeal joint of the index nger of the right hand apply pressure in a posterior direction on the anterior surface of the tibia.
Application o orces by therapist (method) • Small or large amplitude oscillatory movements can be performed as diagonal movements into F/ Ab and F/ Ad while strongly maintaining medial rotation of the tibia (for F/Ab) or lateral rotation of the tibia (for F/Ad). • The patient’s heel should then move lateral to the ischial tuberosity (for F/Ab) and medial to the ischial tuberosity (for F/Ad). • Counterpressure needs to be applied to the thigh so that rotation of the hip is prevented (either over the soft tissues of the thigh or by blocking the greater trochanter with the physiotherapist’s leg).
• The therapist needs to keep close to the patient’s lower leg to enable control of the pressure through the patient’s ankle.
Uses • Examination technique as an ‘if necessary’ procedure. • To restore the range of movement into F/ Ab and F/ Ad in cases of minor intermittent knee symptoms. • To help to thoroughly screen the knee. • To remobilize the knee after injury, immobilization or disuse.
Me d ia l rota tion, la te ra l rota tion (Fig. 8.32, see also Fig. 8.3) • Direction: Medial and lateral rotation of the tibia in relation to the femoral condyles. • Symbols:
A
B
Fig ure 8.32 • Tibio emoral rotation prone: A medial; B lateral. 491
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• Patient starting position:
• It is essential to prevent the forefoot from
○ in exion supine: supine, hip and knee exed
to 90°, foot in the air (see Fig. 8.3) ○ in exion prone: prone with the knee exed to 90° (see Fig. 8.32). • Therapist starting position:
•
○ in exion supine: standing by the patient’s right ○
hip facing the patient’s foot (see Fig. 8.3) in exion prone: standing by the patient’s right thigh facing the patient’s foot (see Fig. 8.32).
• •
Localization o orces (position o therapist’s hands)
•
In f exion supine • The left arm and side hold the patient’s knee. • The left hand, pronated, holds the patient’s
•
forefoot from the lateral side. • The right hand holds the patient’s heel posteriorly and medially.
In f exion pr one • The heel of the right hand holds the medial • • • • •
surface of the patient’s heel. The ngers spread over the sole of the heel with the tips of the ngers reaching the lateral surface. The left hand grasps the dorsum of the patient’s forefoot. The heel of the left hand holds against the foot’s lateral border. The thumb is placed over the sole of the foot. The forearms are directed opposite each other.
•
inverting (for medial rotation) and everting (for lateral rotation) when pressure is applied to its lateral surface by the left hand (M R) or its medial surface by the left hand (LR). Movement takes place at the foot and ankle as well as the knee. This does not make the technique any less effective in producing knee rotation. Variations in the application of forces If the foot and ankle are very painful, the knee rotation may need to be produced by grasping the malleoli. The techniques of AP and PA in slight exion can be adapted so that grades I and II medial and lateral rotation are produced (see Figs 8.34, 8.35). For grades I and II medial rotation of the tibia in this position, an AP pressure through the therapist’s thumbs can be applied to the medial tibial condyle near the joint at the same time as a PA pressure is applied by the therapist’s ngertips against the lateral condyle of the tibia posteriorly and near the joint line. Lateral rotation will be produced if the thumbs apply pressure to the lateral tibial condyle anteriorly at the same time as the ngertips apply pressure to the medial tibial condyle posteriorly. G rades I and II: supine, knee over a soft pillow. O ne of the therapist’s hands palpates the joint line, the other hand grasps around the distal part of the tibia around the malleoli. Rotation is applied by gently rotating the malleoli and xating the knee and femur.
Application o orces by therapist (method)
Uses
In f exion supine • The rotation (medial or lateral) is produced by
• Most useful as a grade IV stretching movement
a pulling action of both hands while the therapist’s body stabilizes the patient’s knee. • Large amplitude movements involving 30° of movement can be performed easily. • Small amplitude grade IV stretching movements can also be performed easily in this position. • Foot and ankle movement will also occur during the knee rotation.
• •
In f exion pr one • Small and large amplitude movements can be produced by a pulling and pushing action of both hands in opposite directions. 492
•
• • •
in exion. Very painful joints (variation, grades I and II). Medial rotation is usually more valuable in treatment than lateral rotation. Tibial medial rotation corresponds to anterior cruciate restraint; tibial lateral rotation corresponds to medial ligament and posterior cruciate restraint. Where functional demonstration indicates knee rotation is stiff or painful. As part of postmeniscectomy rehabilitation. As part of post-tibial plateau fracture rehabilitation.
De s c rip tio n o f te c h n iq u e s
• To encourage restoration of proprioceptive function.
Acces s ory movements o the tibio emoral joint: examination and treatment techniques Ab d uc tion a nd a d d uc tion (see Fig. 8.18) • Direction: Abduction and adduction of the tibia in relation to the femur, best achieved with the knee held approximately 10° short of full extension. • Symbol: Ab, Ad. • Patient starting position, therapist starting position, localization of forces: ○ the position adopted is identical to that described for extension/ abduction ○ the therapist maintains 10–20° of exion by nger support under the patient’s knee.
A
Application o orces by therapist (method) • Abduction movement is produced by the pressure of the therapist’s left hand against the lateral surface of the patient’s knee. • Adduction is produced by pressure against the medial side of the patient’s knee from the therapist’s right hand.
Uses • Examination of end-feel on adduction and abduction: in extension only minimal range of movement should take place with a characteristic end-feel to the movement. If a collateral ligament is ruptured, the range of movement may be excessive and this end-feel becomes ‘mushy’ (Corrigan & Maitland 1994). • To recover lost range of abduction and adduction in 10° of exion.
Longitud ina l move me nt c a ud a d a nd c e p ha la d (see Fig. 8.33) • Direction: Movement of the tibial plateau in a longitudinal caudad direction in relation to the femoral condyles and femoral joint surfaces. • Symbol: • Patient starting position: Supine, lying near the right-hand edge of the couch with the knee supported in a few degrees of exion with a soft pillow.
B
Fig ure 8.33 • Tibio emoral longitudinal movements: A caudad; B caudad – alternative.
• Therapist starting position: Standing by the patient’s right foot facing the knee (see Fig. 8.33A).
Localization o orces (position o therapist’s hands) • Both hands grasp around the tibia as close to the joint line as is possible. • The thumbs overlap to reach the opposite side of the tibial tubercle. • The ngers reach around the medial and lateral borders of the tibia to the posterior surface.
Application o orces by therapist (method) • Small or large amplitude oscillatory movements are produced by pulling lightly or strongly on 493
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the tibia near to the joint line and in line with the shaft of the femur.
Variations in the application o orces • Therapist stands by patient’s right knee facing the foot; both hands grasp around the malleoli and the therapist’s forearms support the tibia. O scillatory movements are produced by the therapist’s arms and upper body (see Fig. 8.33B).
Longitudinal movement cephalad • O ccasionally compression (longitudinal cephalad movement) of the joint surfaces becomes important when combined with other accessory or physiological movements in the treatment of joint surface pain (see Box 8.4). • This compression can be produced as described above with the exception that the tibia is moved towards the femoral condyles in line with the shaft of the femur. • While the joint surfaces are held together (which may serve the purpose of reproducing the ache emanating from the joint surfaces) other movements may be carried out such as AP, PA or exion/ extension with abduction/ adduction or rotation.
A
Uses • Very painful joints (longitudinal caudad). • Minor aching with joint surface loading
B
(longitudinal cephalad). • In conjunction with other accessory or physiological movements. • Stretching stiff collateral ligaments or reducing the loading on very painful joint surface disorders (longitudinal caudad). • Adding to (for example) extension/ abduction to reproduce momentary pain – clinical group 4 (longitudinal cephalad).
P os te roa nte rior move me nt (see Fig. 8.34) • Direction: Movement of the tibial plateau in relation to the femoral condyles in a posterior to anterior direction. • Symbol: • Patient starting position: ○ for grades I and II: supine, lying with the knee carefully supported in a few degrees of exion by a soft pillow (see Fig. 8.34A) 494
C
Fig ure 8.34 • Tibio emoral posteroanterior movement.
De s c rip tio n o f te c h n iq u e s
○ for grades III and IV: prone, lying with the
knee exed to approximately 70° or at the available limit (see Figs 8.34B, C). • Therapist starting position:
○ for grades I and II: standing by the patient’s ○
side facing the patient’s head (see Fig. 8.34A) for grades III and IV: standing by the side of the patient beyond the exed knee and facing the patient’s head; the left tibia rests on the couch, the therapist’s knee is fully exed so that the upper thigh supports across the patient’s distal shin (see Figs 8.34B, C).
Localization o orces (position o therapist’s hands) For gr a d es I a nd II • The hands grasp the patient’s knee from both sides. • The thumbs and heels of both hands are placed around the joint medially and laterally. • The thumbs extend anteriorly over the joint line. • The ngertips of both hands are placed along the posterior surface of the tibia adjacent to the joint line.
For gr a d es III a nd IV • As much of the thumb pads as possible are placed on the posterior surface of the medial and lateral condyles of the tibia with the ngers spread across the tibia laterally, medially and anteriorly. • The left hand supports the patient’s right shin, the heel of the right hand is placed on the posterior surface of the tibia as far proximally as possible, the ngers of the right hand lie over gastrocnemius.
Application o orces by therapist (method) For gr a d es I a nd II • The gentle oscillatory posteroanterior movement is produced by the therapist’s pressure transmitted through the ngertips against the posterior surface of the tibia proximally.
For gr a d es III a nd IV • The stretching oscillatory movements are produced by the therapist’s arms and body
acting through the thumbs (the thumb exors should never be used as this may produce discomfort and the therapist will be unable to appreciate the extent and feel of the movement) or the heel of the hand. • If the heel of the hand is to be used to produce the movement, the pressure against the tibia should originate from the therapist’s arm and trunk. • Three distinct movements can be produced in this case: 1. As the tibia is moved forwards the therapist can, with the right hand, carry the distal end of the tibia an equal distance so that the whole lower leg moves through a parallel line. 2. As the pressure is exerted posteroanteriorly through the therapist’s left hand, the therapist can slightly lift the patient’s distal tibia so that, combined with the PA movement, there will be a degree of knee exion taking place. 3. As the PA movement of the tibia is taking place, the therapist’s right hand can lower the distal end of the tibia so that there is a degree of tibiofemoral extension as the PA movement is taking place.
Uses G r a d es I a nd II • Painful joint movements. • Clinical groups 1 and 3a. • Acute injury or are-up of OA. • Commencement of mobilization after surgery or immobilization.
G r a d es III a nd IV • To restore range in a stiff joint at the limit of exion or other movements. • Clinical groups 2 and 3b. • Postinjury or immobilization stiffness.
Ante rop os te rior move me nt (see Fig. 8.35) • Direction: Movement of the tibial plateau in relation to the femoral condyles in an anterior to posterior direction. The greatest range will be achieved in 10–70° of knee exion. • Symbol: 495
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across the patient’s foot to stabilize the position.
Localization o orces (position o therapist’s hands) For gr a d es I a nd II • The pads of the thumbs are placed against the anterior surface of the tibia either side of the tibial tuberosity. • The ngers rest against the adjacent surfaces of the tibia and bula. • The metacarpophalangeal joints of the thumbs are positioned almost vertically above the pads of the thumbs so that the pressure is directed through these joints.
For gr a d es III a nd IV • The heel of the right hand is positioned over
A
the anterior surface of the tibia immediately adjacent to the joint line. • The ngers spread over the front of the patient’s knee. • The left hand is placed behind the patient’s knee and the palm over the upper calf posteriorly.
Application o orces by therapist (method) For gr a d es I a nd II • Small or large but gentle oscillatory movements B
Fig ure 8.35 • Tibio emoral anteroposterior movement: A grade I; B grade II.
• Patient starting position:
○ for grades I and II: supine, lying with a soft
pillow carefully placed under the patient’s knee supporting the femur more than the tibia and in not more than 10° of knee exion ○ for grades III and IV: supine, lying with the foot resting on the couch so that the knee is exed to approximately 70° or to its available limit. • Therapist starting position:
○ for grades I and II: standing by the patient’s ○
right lower leg facing the patient’s knee for grades III and IV: standing by the patient’s right ankle, right lower leg resting
496
are produced by the therapist’s arms acting through the thumbs. • These nely controlled movements should never be performed by the exor muscles of the thumb.
For gr a d es III a nd IV • The AP movement of large or small amplitude is produced by pressure against the upper end of the tibia. • The patient’s hand posteriorly acts as a support and produces the return movement when a large amplitude is required.
Uses G r a d es I a nd II • Extremely painful knees. • Clinical groups 1 and 3a. • Acute injury. • Acute are-up of OA. • Commencement of mobilization after arthroplasty or other surgical interventions.
De s c rip tio n o f te c h n iq u e s
G r a d es III a nd IV • To restore range in a stiff joint at the limit of exion (can be performed in other positions such as extension, rotation, abduction, adduction). • Clinical groups 2 and 3b. • Postinjury or immobilization stiffness.
La te ra l move me nt a nd me d ia l move me nt (Fig. 8.36) • Direction: Movement laterally or medially of the tibial plateau in relation to the femoral condyles, in any position of exion or extension of the knee (90° of exion in this case). • Symbols
• Patient starting position: Supine, hip and knee exed accordingly and the foot resting on the couch. • Therapist starting position: Standing level with the patient’s foot facing the patient’s head.
Localization o orces (position o therapist’s hands) La ter a l movement (Fig. 8.36A) • The heel of the right hand is placed on the medial condyle of the tibia. • The heel of the left hand is placed on the lateral epicondylar area of the femur. • The therapist leans forward and extends both wrists so that both forearms are directed parallel to each other. • The right forearm is positioned in a slightly lower plane to the left hand.
Media l movement (Fig. 8.36B) • The heel of the right hand is placed on the medial epicondylar area of the femur. • The heel of the left hand is placed on the lateral condyle of the tibia. • The left forearm will be positioned in a slightly lower plane than the right.
Application o orces by therapist (method) A
• The technique is merely one of pushing the arms towards each other. • For lateral movement it is essential to apply the pressure along the line of each forearm in the correct plane such that, if the patient’s knee was not there, the therapist’s right arm would pass parallel to but below the left arm. • For medial movement the left arm would pass parallel to but below the right arm.
Uses • Pain and stiffness of the knee in the lateral and
B
Fig ure 8.36 • Tibio emoral movements: A lateral; B medial.
medial directions. • To complement the recovery of Ab or Ad or E/ Ab, E/ Ad, F/ Ab, F/ Ad. • After knee debridement to help to regain natural shearing forces across the joint surfaces. • To complement recovery after collateral ligament injury. 497
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Tib io e mora l tre a tme nt te c hniq ue s und e r c omp re s s ion Figures 8.37 and 8.38 are examples of how treatment techniques may be adapted under compression.
Acces s ory movements o the patello emoral joint: examination and treatment techniques Comp re s s ion (see Fig. 8.21) • Direction: Compression of the posterior surface of the patella against the intercondylar articular surfaces of the femur. • Symbol: • Patient starting position: Supine, lying with a pillow under the knee and the knee in a few degrees of exion. • Therapist starting position: Standing by the patient’s right knee facing the patient’s head.
Localization o orces (position o therapist’s hands) • The left hand is placed under the posterior surface of the patient’s femur distally. • The heel of the right hand is placed over the patella.
Fig ure 8.37 • Example o treatment under compression: f exion or accessory movement in f exion position. 498
• The centre of the patella ts between the therapist’s thenar and hyperthenar eminences. • The right forearm should be directed vertically through the patient’s knee.
Application o orces by therapist (method) • The technique is produced by a gentle squeezing of the patella against the femur. • Pressure should be applied gently and slowly against the patella. • The patient should report any discomfort or pain as the pressure is applied. • If no discomfort is felt, maximum pressure can be applied against the patella and a strong small amplitude grade IV+ movement produced.
Variations in the application o orces • When this technique is painless or only minimally painful a technique can be used where the patella is hit sharply by the heel of the therapist’s hand so as to knock the patella sharply against the femur. • The rst session should be very short (not exceeding 20 seconds) and an assessment made on the following day to guide whether stronger techniques can be used or whether, because an exacerbation has been caused, gentler techniques are included. • Can be useful as a means of identifying patellofemoral pain by adding compression of
Fig ure 8.38 • Example o treatment in weight-bearing position: f exion or PA/AP movements.
De s c rip tio n o f te c h n iq u e s
the patella to functional activities such as squatting. This can also then serve as a progression of treatment.
Uses • Minimal pain emanating from the patellofemoral articulation during loaded activities such as squatting, descending stairs or sitting to standing. • To reproduce pain originating from the patellofemoral joint surfaces. • In combination with other patellar movement such as longitudinal movements. • Patellofemoral OA.
Dis tra c tion (see Fig. 8.20) • Direction: Movement of the patella away from the femoral articular surfaces. • Symbol: Distr. • Patient starting position: Supine, knee in extension (or pain-free position). • Therapist starting position: Standing level with the patient’s knee, facing across the patient’s body.
the distraction movement by gently moving both elbows towards each other (see Fig. 8.20b). • As well as a technique in its own right the distraction of the patella can then be accompanied by other patellar movements (e.g. medial, lateral, longitudinal, rotational and diagonal).
Uses • Very painful patellofemoral joint surface disorders (clinical groups 1 and 3a). • Pain relief in chondromalacia patellae. • As a means of progressing pain-free movements of the patella in other directions. • Stretching the retinaculum and soft tissue attachments of the patella (clinical groups 2 and 3b).
Tra ns ve rs e move me nt me d ia lly a nd la te ra lly (Fig. 8.39) • Direction: Movement of the patella in a transverse medial direction in relation to the femoral intercondylar articular surfaces.
Localization o orces (position o therapist’s hands) (see Fig. 8.20A) • Both thumbs are placed in the space between the patella and femur medially (or laterally). • Both index ngers are then placed in the space on the opposite side. • The ngers and thumbs are then gently squeezed together to reach under the patella. • At the same time the wrists are extended and radially deviated so that the ngers and thumbs lift against the undersurface of the patella.
Application o orces by therapist (method) • The technique is a very gentle, slow oscillatory movement consisting of raising and lowering the patella. • The patella should not be lowered to the extent whereby it comes into full contact with the femur. • Care should be taken to avoid discomfort under the patella.
Variations in the application o orces • The therapist places the bases of both hands lateral and medial to the patella, and performs
Fig ure 8.39 • Patello emoral transverse movement medially. 499
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• Symbols: • Patient starting position: Supine, lying with knee in extension. • Therapist starting position: Standing by the patient’s right knee, facing across the patient’s body.
Localization o orces (position o therapist’s hands) • The pads of both thumbs are placed, pointing towards each other, against the lateral border of the patella. • The ngers of the left and right hands point medially to rest across the distal end of the patient’s femur and proximal end of the tibia, respectively. • The thumbs are hyperextended at the interphalangeal joints to bring as much of the pads as possible into contact with the lateral border of the patella.
Application o orces by therapist (method)
• In combination with pain-relieving distraction or discomfort-provoking compression.
Longitud ina l move me nt c a ud a d a nd c e p ha la d (Fig. 8.40) • Direction: Movement of the patella in a longitudinal caudad direction in relation to the femoral intercondylar articular surfaces. • Symbol: • Patient starting position: Supine, lying with knee in extension. • Therapist starting position: Standing by the patient’s right knee facing across the patient’s body, or facing the patient’s feet for stronger grades of movement.
Localization o orces (position o therapist’s hands) • The heel of the left hand, near to the pisiform bone, is placed against the superior margin of the patella.
• O scillatory movements of the patella are produced by the therapist’s arms acting through the thumbs. • G rade I should produce 5 mm of movement of the patella from its resting position. • For other grades of movement the patella is displaced more medially, reaching the limit of its excursion for grade III and grade IV movements.
Variations in the application o orces
A
• Transverse laterally is merely the reverse of the transverse medial movement. • The patella can also be mobilized in the transverse direction while the patient adopts a position of the knee which relates to a painful or stiff activity (e.g. squatting). • Alternatively, the patient’s patella can be realigned with a transverse pressure during an activity which is painful (e.g. stepping up). • If the pain diminishes with the realigned transverse pressure the therapist can utilize this in treatment and rehabilitation.
Uses • Painful or restricted transverse movement of the patella. 500
B
Fig ure 8.40 • Patello emoral longitudinal movements: A caudad; B cephalad.
De s c rip tio n o f te c h n iq u e s
• The left wrist is extended. • The left forearm is directed distally. • The right hand, pointing proximally, is placed over the patella. • The ngers and thumb of the right hand pass either side of the heel of the left hand. • The right hand serves three purposes: 1. Providing stability for the left hand 2. G uiding the patella during movement 3. Applying compression to the patella if desired.
Application o orces by therapist (method) • The caudad movement of the patella is produced by the heel of the therapist’s left hand while the direction of the movement is guided by the right hand. • The therapist’s two hands and the patient’s patella should move as a single unit.
Special testing The purpose of special tests is to move the patella through a full amplitude of movement by moving the patella in any radius of a circle while applying a compressive force against the anterior surface of the patella, thereby rubbing the posterior surface of the patella against the femur.
Two rotary movements The directions of the rotary movement are illustrated in Figure 8.19.
• Rotation of the patella about the anatomical longitudinal axis producing contact between the medial articular facet of the patella and the medial condyle of the femur. • Rotation in the coronal plane around a sagittal axis (see Fig. 8.22).
Variations in the application o orces
P a te llo e mora l move me nts in kne e e xion (e xa mp le s o tre a tme nt) (Fig. 8.41)
• Longitudinal cephalad movement: the same hand
• Direction: Any direction of movement of the
positions over the patella are used as for the caudad technique, but the movement is produced through the ulnar border of the therapist’s right hand. To guide the direction of the movement the therapist uses the palm of the right hand (cupped over the patella) and the cupped base of the palm of the left hand. • If compression is required during the movement, the patella can be pressed against the femur by the therapist’s right hand. • If the movement signs indicate, the movement described above can be combined with a medial inclination whereby the point of contact against the superior border of the patella is moved slightly laterally and the direction of the arms altered so that the diagonal movement direction can be performed. Likewise, a lateral inclination can be performed.
patella in relation to the femur with the patient’s knee in exion. • Symbols: In knee F 60°, DId P/ F caud and ceph, med. • Patient starting position: Sitting with the knee over the edge of the couch; alternatively, weight bearing. • Therapist starting position: Standing by the side of the patient’s knee.
Uses
Application o orces by therapist (method)
• Patellofemoral OA (clinical group 3b). • Pain with this or inclined longitudinal movement directions. • In combination with compression or distraction as progressions of treatment. • Rotation around longitudinal axis or sagittal axis.
Localization o orces (position o therapist’s hands) • The right palm is cupped over the patella. • The heel and ulnar border of the left hand is placed against the superior margin of the patella. • The lower legs stabilize the patient’s lower leg in the required degree of exion.
• From this starting position the therapist can produce a variety of oscillatory movement directions (cephalad, caudad, angled, rotary, medial, lateral, with the addition of compression). • Movement is produced by arm movement acting through the hands. 501
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A
B
C
Fig ure 8.41 • Treatment example: in 60° f exion, longitudinal movements o patello emoral joint: A caudad; B cephalad; C transverse medial.
Uses • Stiff knee exion after injury or prolonged periods of immobilization (Fig. 8.41A, B). • Minor symptoms (group IV) (Fig. 8.41A–C).
Acces s ory movements o the s uperior tibiof bular joint: examination and treatment techniques Examination and treatment techniques may be performed in any position: supine, prone or side lying. Side lying permits many adaptations of the techniques to the knee and foot positions.
Ante rop os te rior move me nt (see Fig. 8.23) • Direction: Movement of the head of the bula in an anterior to posterior direction in relation to the bular articular facet on the tibia. • Symbol: • Patient starting position: Side lying with the right hip and knee exed and the lower leg resting on the couch. • Therapist starting position: Standing in front of the patient’s knee (if carried out in supine with knee exion: sitting on the patient’s foot to stabilize it, facing the patient’s knee). 502
Localization o orces (position o therapist’s hands) • The pads of both thumbs are placed against the anterior border of the head of the bula. • Both thumbs point posteriorly. • The ngers of both hands spread around the patient’s knee to help stabilize the thumbs.
Application o orces by therapist (method) • Anteroposterior movements are exerted against the head of the bula through stable thumbs. • It is extremely dif cult to differentiate between different grades of movement but they can be varied by altering the strength of the pressures.
Variations in the application o orces • If the addition of compression is necessary, the heel of the left hand is placed over the head of the bula laterally while the ngers lie over the knee. The right thumb maintains its contact against the anterior margin of the bula. The left forearm is directed so that it can apply a medially directed pressure against the head of the bula as well as assisting the right thumb in its anteroposterior pressure (see Fig. 8.23B). • Anteroposterior movement without or with compression can be performed with the patient in side lying. The medial aspect of the lower leg should be fully supported on the couch and the patient’s ankle must be in a loose neutral
De s c rip tio n o f te c h n iq u e s
mid-range position. The movement is then produced through the therapist’s thumbs or cupped hands in much the same way as shown for the inferior tibio bular joint.
Uses • Pain and stiffness of the superior tibio bular joint. • To help the recovery from peroneal nerve entrapment at the head of the bula. • To complement mobility of the inferior tibio bular joint and thus the foot and ankle.
P os te roa nte rior move me nt (see Fig. 8.24) • Direction: Movement of the head of the bula in a posterior to anterior direction in relation to the bular articular facet on the tibia. • Symbol: • Patient starting position: Side lying, with right leg in hip and knee exion, lower leg resting on plinth (if carried out in prone, lying near the right edge of the couch with the knee exed approximately 30° for convenience). • Therapist starting position: Standing behind the patient.
Localization o orces (position o therapist’s hands) • The pads of both thumbs are placed against the posterior border of the head of the bula. • The ngers of the left hand spread medially across the patient’s upper calf. • The ngers of the right hand reach anteriorly around the bula.
Application o orces by therapist (method) • Posteroanterior mobilizing is performed by pressure from the therapist’s arms through the thumbs against the head of the bula. • The movement must not be produced by the muscles of the thumbs as this immediately becomes uncomfortable for the patient.
the bula while the thumb of the other hand produces the PA movement (see Fig. 8.24B). • The posteroanterior movement can also be performed with or without compression with the patient in side lying in the same way as that described for anteroposterior movement, apart from the thumbs or heel of the hand being placed against the anterior border of the head of the bula. • For examination purposes the posteroanterior movement can be tested with the patient lying supine with the hip and knee exed. A pulling pressure is then applied behind the head of the bula with the ngers of the left hand. • The PA mobilization can also be performed using the left thumb with the patient in supine and the leg in a degree of SLR in cases of nerve entrapment.
Uses • Pain and stiffness of the superior tibio bular joint in this direction. • To help in the recovery of peroneal nerve entrapment at the head of the bula. • To complement mobility of the inferior tibio bular joint and therefore the foot and ankle.
Longitud ina l move me nt c a ud a d a nd c e p ha la d (see Fig. 8.25) • Directions: Movement of the bula in a longitudinal caudad and cephalad direction in relation to the tibia. • Symbol: • Patient starting position: Prone, lying with the knee exed to a right angle. • Therapist starting position: Standing next to the patient’s foot, facing across the patient’s body.
Localization o orces (position o therapist’s hands) • O ne hand holds the patient’s foot, the other palpates movement of the bula.
Variations in the application o orces
Application o orces by therapist (method)
• The movement can be performed under
• Caudad movement is produced by strongly
compression by changing the position of the therapist’s hands so that the heel of the hand is placed against the lateral surface of the head of
inverting the patient’s heel (see Fig. 8.25A). • Cephalad movement is produced by the therapist everting the patient’s heel, at the 503
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same time pushing the inferior angle of the bula cephalad with both thumb pads. • This movement can readily be felt in the normal subject by palpating the head of the bula with one hand while inverting and everting the patient’s heel with the other hand.
Variations in the application o orces • The longitudinal movements of the bula can be produced with the addition of compression. O ne hand can be used to apply compression laterally to the head of the bula while the other hand inverts and everts the patient’s heel.
• The longitudinal movements with or without compression can also be performed with the patient in side lying with the foot free of the edge of the couch so that the patient’s heel can be inverted and everted readily. • Longitudinal movement caudad can be applied locally to the head of the bula (see Fig. 8.25B).
Uses • Stiffness of the bula in the longitudinal directions principally in relation to inversion and eversion injuries or disorders of the foot and ankle.
Cas e s tudy 8.1 Anterior knee pain J ohn D is a 24-year-old s tudent whos e hobbies include volleyball, mountain biking, jogging and s ki touring.
arthros copy – nothing revealed, no res ults . GP: s ent to phys iotherapy.
Kind o d is ord e r
Pas t his tory
Symptoms in knee area: s tabbing pain. Had arthros copy – nothing s pecial revealed. A ter a s eries o treatments in open-chain quadriceps bench, s ymptoms increas ed. Has di f culties in walking and running. No s ports pos s ible at the time.
Never had problems with knee, hip or lumbar s pine (light backache in middle o s pine a ter longer periods o s itting, never s ought help).
Bod y c ha rt As illus trated in Figure 8.42.
Ac tivity limita tions a nd 24-hour b e ha viour o s ymp toms normal walking, a ter c. 50 m. Can continue, limps s lightly. 100% immediately when s itting down. * 1a when s itting with legs bent gets res tles s a ter c. 10′ and s lightly pain ul. Needs to move leg continuous ly. *Running, jumping, volleyball training not pos s ible becaus e pain becomes too s evere. Tried volleyball training 2 weeks ago; s ymptoms increas ed or about 2 days .
P a s t a nd p re s e nt his tory Pres ent his tory In volleyball match c. 4 months ago ell on knee; s light 1a . pain in which increas ed over the next ew days Doctor advis ed quadriceps s trengthening and s tretching. Fitnes s s tudio (s el -s upported): pain increas ed a ter intens e exercis es on open-chain quadriceps bench. Orthopaedic s urgeon: X-ray, MRI,
504
Sp e c ia l q ue s tions GH ; no medication; X-ray, MRI normal; arthros copy (6 weeks ago: normal. Report: cartilage at s pot o can be dented lightly).
P la nning o p hys ic a l e xa mina tion • • •
Moderately s evere s ymptoms : tes ts procedures until ons et o P 1 . Symptom mechanis ms : nociceptive (s timulus –res pons e related). Pos s ible s ources o dys unction: PF joint, TF joint (m ay re er rom hip, lumbar s pine, neurodynamics ).
P hys ic a l e xa mina tion • • •
Obs ervation: was ting o medial as pect o quadriceps PP Functional demons tration: getting up s tep – taking weight o body on leg ( = c. 30° knee exion) 1a
• • • •
Knee active movements : F, F/Ad, E, E/Ad , F/Ab, E/Ab: s lightly res tricted, IV− VMO recruitment in weight-bearing in 20° F (moving rom plinth to weight bearing on both legs ) ; correction o patella medially: s lightly
De s c rip tio n o f te c h n iq u e s
Cas e s tudy 8.1—cont’d
1 1a
1 1a Always together
Fig ure 8.42 • Body chart o J ohn D.
•
Acces s ory movements o TF joint in EOR F as well as in EOR E: all , • PF joint: in c. 15° F (no pain) Do: P/E acces s ory PP: ISQ movements caud, ceph, caud/med, ceph/med (Fig. 8.43) med, med/caud (Fig. 8.43) All other P/F movements , De c is io n: Treat P/F s igns , s hort o P 1
D1, Rx1 In s upine, 15° F (be ore P) do P/F caud, ceph, caud/ med, ceph/med med, med/caud III−, rhythm s mooth, rel. s low s peed c. 5′, alternating techniques As s es s ment while: a ter c. 3–4′ P 1 later in range, a ter c. 5′: ISQ
C/O: ‘lighter’ P/E: Fct. demo +, but can s tep up ☺ E/Ab , ☺ F/Ab , ☺
Warned patient: m ay increase; should com pare walking, night, sitting
505
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Cas e s tudy 8.1—cont’d Plan (D2, Rx2) •
•
Hypothes es reg. s ources : P/F dys unction conf rmed; T/F impairment s eems to improve with P/F treatment (hip, Lx, NS: probably not involved, however will need quick s creening in next ew s es s ions ). Procedures P/E: Cave: may los e P/E **! Add in s quat, getting up rom chair S creen: hip, s creen Lx (both components IF no changes in reas s es s ment; i changes : s creen only one component and leave other to Rx3) Rx: P/F (probably as in Rx1) S elf-m anagem ent: objective – control P: • ‘s tretch’ rectus emoris ? • automobilizations patella? • may cons ider corrective tape to enhance VMO recruitment in weight bearing.
Screening Lx:
Rx2a as Rx1 – grade III c. 5′ (a ter c. 4’ P 1 , R1 later in range)
D2, Rx2 •
•
•
C/O: Felt lighter a ter Rx1; *walking was pos s ible or a longer range – c. 500 m without pain *Sitting: pain intens ity (be ore c. 7/10, now c. 4/10). *Getting up s tairs was pos s ible, however became very pain ul 1a a ter c. 6 s teps . P/E: *PP 1a Fct. demo: getting up s tep – is pos s ible; 30–60° F 1a *Squat (holds plinth): c. 50° F, *VMO tes t in 20° F, take weight on both legs : E/Ab , *F/Ab , little Screening hip (Fig. 8.44):
C/O: PP ‘lighter’ P/E: Fct. Demo (get up s tairs ) 30–60° F ☺ a Squat 50° (intens ity . )☺ VMO tes t , 20° (intens ity )☺ F/Ab , ☺
Rx2b Stretching rectus emoris in s tanding Hip E 10°, knee F ull range Pulls rontal s ide 5×, c. 10′ •
C/O: ISQ P/E: Fct. Demo (get up s tairs ) 1 s tep , ☺ 1a 2nd s tep: P 1 o thigh 1a ++ 3rd s tep 1a Squat 70° (intens ity ) ☺ Info/Instr. at end of session: s hould per orm RF exercis e at leas t 3–4×/day; each time 1 s eries /5× rep.; additionally s hould try exercis e 3–5× i 1a
R2 (IV++)
P' 1
R1
P1
Fig ure 8.43 • P/E accessory movements.
506
Fig ure 8.44 • F/Add o hip.
De s c rip tio n o f te c h n iq u e s
Cas e s tudy 8.1—cont’d Plan (Rx3)
Rx3c
•
Repetition o RF exercis e; 5x/ca 10′ without pain
• • •
Continue R× o PF joint; pas s ive mobs may progres s towards pos ition o 30–40° F Check RF exercis e Further automob. neces s ary? VMO exercis e? (maybe with corrective tape? )
Rx3d
D5,Rx3
Automob. PF – large amplitude caudad movements Without pain. c. 2′
•
Rx3e
•
C/O: ‘Better’, ‘Walking hardly pain ul’ *Getting up s tairs : 1 s tairway (15 s teps ) pos s ible without P; 2nd s tairway (15 s teps ) increas es , but may continue *Getting down s tairs : + a ter c. 10 s teps *Squat: s eems eas ier Does not run or jump yet E ect o RF exercis e: did it c. 3×/day; orgot to do it once on s tairs P P/E: PP * Fct. Demo: Stairs up: a ter 10× P 1 30–60°F Stairs down: a ter 5× P 1 30–60°F 1a *Squat: ull range, 70°F – EOR *VMO in 20°F: takes on weight without pain; a ter c. 3× P 1
As Rx2a: no s ymptoms During Rx: progres s ion: In 30° F: do Rx caud, caud/med; med; lat/caud III−, s hort o P c. 5–6′ A ter c. 4′ P 1 later in range; a ter c. 5′ ISQ
C/O: P/E: Stairs 20× without pain ☺ Stairs 10× without pain ☺ Squat: range ISQ, P intens ity (5/10) ☺ J ump: s mall jump pos s ible s P ☺
Rx3b As Rx3a Progres s to 45°F
C/O: P/E: Stairs 30× without pain ☺ Stairs 20× without pain ☺ Squat: range ISQ, P intens ity (2/10) ☺ J ump: s mall jump pos s ible s P ☺
J umping als o lighter Squat: pain ree
VMO recruitment 5×, then P; did automob. PF: could continue with exercis e A ter 5× VMO ex. P s tarted again: tried RF ex P decreas ed; however elt that PF automob. helped better to in uence pain
End o s es s ion: in o and ins tr. to patient • •
Should per orm RF exercis e/automob. i ever s ymptoms VMO exercis e: s eries o 5×; i s ymptoms , per orm either RF or PF automobilization; s hould continue i pos s ible in 3–4 s eries
Plan (Rx4) • •
Continue treatment as in Rx3 May progres s activities to jumping and running. I P increas es : per orm automob. and/or RF exercis e
Rx4: Retrospective assessm ent •
•
Rx3a
J umping s eems lighter Squat hardly pain ul
•
•
•
Patient eels much better: s quat hardly pain ul; getting up s tairs : almos t 2 s tairs up and down without pain. However, i moving quicker, P may s tart. Tried to run or c. 1 km – then s ymptoms s tarted; orgot to do exercis es at moment o increas e o pain. Overall level o activity has increas ed, es pecially normal walking and s tairs . However, did not continue running; did not s tart volleyball training and jumping. Would like to s tart training ASAP. Patient elt that particularly pas s ive mobilizations helped him bes t. Knows that exercis es may control pain in daily li e; however, orgets it too o ten. P/E ** remained as a ter Rx3.
Summa ry o re ma ining s e s s ions • •
• •
Overall treatment las ted 9 s es s ions . Pas s ive mobilizations were continued as above until s es s ion 8; progres s ion towards 60° F; a ter 6th s es s ion compres s ion IV− was added to the pas s ive movement s eries . VMO recruitment exercis es continued as s tarted in Rx3. Sel -management to control pain included RF s tretches and light large amplitude automobilizations o patella.
507
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Cas e s tudy 8.1—cont’d •
•
Res umed volleyball training a ter 4th s es s ion. However, jumping as in s mas h training was s till pain ul and patient was not able to jump ully until about the 10th s es s ion. A ter 9th s es s ion: DLA 100% s ymptom ree; did not eel capable yet to ull explos ive jumping during volleyball. Stretching and PF automobilizations in uenced pain directly and patient integrated thes e s trategies in movement behaviour during warming up and during volleyball training.
•
•
A ter 9th s es s ion: interruption o treatment; reas s es s ment a ter 2 weeks : patient had continued improving and elt c. 95% back to normal daily li e and s ports activities . Reas s es s ment a ter another 4 weeks : 100% normal daily li e and s ports activities . Patient continued with s el -management exercis es and with VMO training, es pecially during warming-up o volleyball training (3×/week).
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C H AP TE R C O N TE N TS Introd uc tion
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Life s tyle fa c tors a nd mus c ulos ke le ta l foot a nd a nkle d is ord e rs
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Key words Anatomy and biomechanics , clas s if cation, clinical practice ramework, examination, interventions , motor control impairment, movement behaviour, movement impairment, therapeutic exercis e, pas s ive movement
Intro duc tio n Foot and ankle problems are highly prevalent. Population-based studies indicate that between 18 and 63% of people report pain, aching, or stiffness in their feet (H ill et al. 2008, Menz et al. 2010). Musculoskeletal foot and ankle problems are commonly seen in primary care consisting of 8% of all musculoskeletal consultations (Menz et al. 2010). 5 12
The role of manual therapy in the intervention of musculoskeletal foot and ankle disorders is well established (Bronfort et al. 2010). In contemporary manual therapy practice musculoskeletal foot and ankle disorders should be considered in a multifactorial bio-psychosocial framework (Kangas et al. 2011). Therefore, the role of manual therapy extends far beyond manual techniques. Manual therapy practice should be a process involving the evaluation of the disorder and implementing an intervention based on evaluation. This process should consider the physical and the psychosocial dimensions of the disorder.
Anatomy and regions o the oot and ankle The foot consists of 28 irregularly shaped bones, over 30 joints, 32 muscles and over 100 ligaments. All these structures have to work synchronously to ful ll the high requirements of the foot and ankle. The foot alternates in form and function between a exible structure for shock-absorption during loading response and a rigid lever for propulsion during terminal stance of the gait cycle. Considerable forces act on the foot and ankle during normal daily activities. For example, a joint contact force for the talocrural joint (TCJ) can range from three to ve times the body weight during the stance phase of gait (Kleipool & Blankevoort 2010). The foot can be divided into different regions based on anatomy, arches of the feet, functional regions and for examination and treatment purposes.
In tro d u c tio n
Anatomically the foot can be divided into hindfoot, midfoot, and forefoot (Fig. 9.1). The hindfoot consists of the talus and the calcaneus, the midfoot consists of the navicular, cuboid and cuneiform bones and the forefoot consists of the metatarsals (referred to as rays) and phalanges (H amill et al. 1995). Classically, the arches of the foot have been de ned as medial longitudinal, lateral longitudinal and transverse. From a functional perspective, the arches can be divided into medial, central and lateral
(Fig. 9.2). The medial arch consists of the talus, calcaneus, navicular, medial cuneiform and the rst metatarsal bones. The rst metatarsal, medial cuneiform and the navicular bones form the rst ray. The central arch consists of the intermediate and lateral cuneiforms and the second and the third metatarsal bones. The lateral arch consists of the calcaneus, cuboid and the fourth and the fth metatarsal bones. The fth metatarsal and cuboid bones form the fth ray.
The bones and arches o the oot
A
B
Talus Calcaneus Metatarsal Cuneiform Navicular I–V Cuboid
C
D
Fig ure 9.1 • The bones of the foot: A dorsal aspect; B plantar aspect; C lateral aspect with the lateral longitudinal arch; D medial aspect with the medial longitudinal arch.
Fig ure 9.2 • Medial, central and lateral arches of the foot. The shaded area shows the central arch of the foot.
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The medial and lateral arches are more exible and are actively weight-bearing arches. Whereas, the central arch is more unyielding and passively contributes to the foot and ankle construct. For manual examination and treatment it is convenient to divide the foot and ankle into the hindfoot and forefoot. The hindfoot consists of the distal tibio bular joint, talocrural joint (TCJ), subtalar joint (STJ) and surrounding soft tissue structures. The forefoot consists of the midtarsal joint (MTJ), intertarsal joints, tarsometatarsal (TMT) joints, intermetatarsal spaces, metatarsophalangeal (MTP) joints, interphalangeal (IP) joints, and surrounding soft tissue structures.
Movements o the oot and ankle O ptimal function of the foot and ankle is based on the synchronization of the movements of individual joints. Single-joint movements occur in distinctively different directions (Nester et al. 2001, Arndt et al. 2004, Tweed et al. 2008). H owever, in functional movements of the foot and ankle independent movements of single joints are seldom, if impossible. The actions of the joints are highly inter-related and an action at one single joint will in uence the other joints. Moreover, movements are often combined or coupled between the joints. For example, in the ankle one-third of the inversion and eversion occurs in TCJ and two-thirds in STJ (Kleipool & Blankevoort 2010).
Axes and planes o movements In this text, the terms eversion and inversion (EV and INV, respectively) are used to describe movements around an anteroposterior axis of the foot. These movements take place in the frontal plane. Plantar exion and dorsi exion are used to describe movements around a transverse axis of the foot. These movements take place in the sagittal plane. Abduction and adduction are used to describe movements around a vertical axis of the foot. These movements take place in the transverse plane (Arndt et al. 2004). The terms pronation and supination (Pron and Sup) are used to describe the triplanar motions of the subtalar joint (STJ) and midtarsal joint (MTJ). These movements are assumed to occur around an axis of the STJ and MTJ (Nester et al. 2001, Arndt et al. 2004) These de nitions are used throughout the text – apart from in the section 5 14
on techniques. In the section on passive movement techniques, pronation and supination are used to describe the triplanar movement of the whole foot and ankle. The movement of the hindfoot around the vertical axis has been called ‘rotation’. This is to make it easier to separate the hindfoot and forefoot movements. Furthermore, the rotations of the hindfoot are so closely related to the rotations of the lower leg, that it is reasonable to maintain the same terminology in clinical practice. In the section on techniques, the movement directions are de ned in Figure 9.4.
Movements o the s ingle joints Dis ta l tib io b ula r joint (s ynd e s mos is ) The distal tibio bular (syndesmosis) joint is formed by two bones and four ligaments. The distal tibia and bula form the osseous part of the syndesmosis and are linked by the distal anterior tibio bular ligament, the distal posterior tibio bular ligament, the transverse ligament and the interosseous ligament (H ermans et al. 2010). The main function of the distal tibio bular syndesmosis is to provide stability for the ankle (Norkus & Floyd 2001, H ermans et al. 2010). Stability of the distal tibio bular syndesmosis is necessary for proper functioning of the ankle and lower extremity. Ankle sprain injury may result in widening of the ankle mortise due to increased length of the syndesmotic ligaments (H ermans et al. 2010). This may be felt in passive mobility examination of the distal tibio bular joint. During ankle plantar exion and dorsi exion, some movement normally occurs at the distal tibiobular joint. When the foot is moved from a plantar exed position to a dorsi exed position, the joint permits approximately 1 to 2 mm of widening at the mortise (Norkus & Floyd 2001). Movement of the bula occurs at the distal tibio bular joint. While in the bular groove of the tibia, the bula rotates around its vertical axis when the ankle is plantar exed and dorsi exed. Lateral bular rotation is approximately 3° to 5° with dorsi exion, and medial rotation is 3° to 5° with plantar exion (Norkus & Floyd 2001).
Ta loc rura l joint The talocrural joint (TCJ) is formed between the articulation of the distal parts of the tibia and bula with the talus. The TCJ may be considered to
In tro d u c tio n
have a single axis of movement. When the TCJ is in a neutral position, the axis of the joint passes through the medial malleolus just below the lateral malleolus. Since the lateral malleolus lies more distally, the axis of the TCJ is angled 20°–30° in the frontal plane. Therefore, the dorsi exion of the TCJ is coupled with abduction and plantar exion is coupled with adduction (H amill et al. 1995). The normal range of motion of the TCJ in dorsi exion is 20°–30°, and in plantar exion 40°–50° (Schuenke et al. 2006). H owever, there are individual variations: a professional ballet dancer would have dif culty managing with only average mobility, whereas another person with different requirements may have below average mobility without any problems.
Sub ta la r joint The subtalar joint (STJ) is located between the talus and the calcaneus, and it has three separate articulations. The axis of rotation of the STJ runs obliquely along the line from the plantar posterolateral surface of the talus to the dorsal anteromedial surface of the talus. The movements of the STJ are pronation and supination (H amill et al. 1995). The normal range of motion of the STJ in pronation is 10°, and in supination 20° (Schuenke et al. 2006). Movements of the TCJ and STJ are partially combined. The maximal range of motion for inversion–eversion occurs at two-thirds of the level of the STJ and at one-third of the level of the TCJ (Kleipool & Blankevoort 2010).
Mid ta rs a l joint The midtarsal joint (MTJ) is capable of movement in all three cardinal body planes, either in isolation or in combination (Nester et al. 2001, Tweed et al. 2008). The predominant motion plane of the MTJ varies between subjects; some subjects have a predominance of frontal plane motion, and others have a predominance of transverse plane motion (Nester et al. 2001). In MTJ, eversion and inversion movements can be coupled in a different manner during the stance phase of gait. Between heel strike and forefoot loading, the MTJ can invert, adduct and dorsi ex, but it everts, abducts and plantar exes after heel-off. This illustrates the complex and variable functional characteristics of the MTJ (Nester et al. 2001). During the stance phase of gait, frontal plane movements of the MTJ occur
in the opposite direction of the hindfoot (Tweed et al. 2008).
Ra ys The rays are formed in the longitudinal line of the foot. The tarsometatarsal joints are the main articulation of the rays. These joints are gliding planar joints and are numbered one to ve (H amill et al. 1995). The intertarsal joint between the medial cuneiform and navicular bones may be included in the rst ray. The axes of the rst and fth rays are oblique. In the rst ray dorsi exion is coupled with inversion and adduction, and conversely, plantar exion is coupled with eversion and abduction. Whereas, in the fth ray dorsi exion is coupled with eversion and abduction, and plantar exion is coupled with inversion and adduction (H amill et al. 1995). It is noteworthy, that the rst and the fth rays are the only rays that can be actively supported towards plantar exion, i.e. on the ground.
The
rs t me ta ta rs op ha la nge a l joint
There are ve metatarsophalangeal (MTP) joints. H owever, the movements of the rst MTP joint have a crucial role in the functioning of the foot and ankle. The movements of the rst MTP joint are dorsi exion and plantar exion. The normal range of motion of the rst MTP joint in dorsi exion is 70°s, and in plantar exion 45° (Schuenke et al. 2006). During pre-swing of the gait the rst MTP joint is dorsi exed 55° (Perry 1992). The motion of the rst MTP joint is coupled with the movements of the rst ray. Dorsi exion of the rst MTP joint is diminished as the rst ray dorsi exes (Roukis et al. 1996). This means that the plantar exion of the rst ray is a prerequisite for the dorsi exion of the rst MTP joint in closed kinetic chain. This phenomenon is easy to prove in a clinical setting. Normally in the standing position dorsi exion of the rst MTP joint will result in plantar exion of the rst ray and rising of the longitudinal arch. Whereas if plantar exion of the rst ray does not occur it will limit the dorsi exion of the rst MTP joint. The dorsi exion of the MTP joints is related to an important function called the ‘windlass’ mechanism. This mechanism provides stability of the foot during propulsion and contributes to the ef cient transfer of force during propulsion (H errmann 1995). 5 15
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Mus c ulo s ke le tal fo o t and ankle dis o rde rs Typical medical diagnos es o the oot and ankle Medical diagnosis aims to identify structural pathology and/ or pathophysiological processes responsible for the disorder. Achilles tendinopathy, plantar fasciitis, hallux valgus and chronic ankle instability are typical medical diagnoses of musculoskeletal foot and ankle disorders. H owever, identifying pathological structures does not explain the mechanism leading to pathology. Plantar fasciitis is used as an example to describe the challenges of making speci c structural diagnosis. Chronic ankle instability is used as an example to describe the multifactorial nature of foot and ankle disorders.
P la nta r fa s c iitis Plantar heel pain is a common disorder which is estimated to affect 10% of the general population at some time during their life (Crawford & Thomson 2003). The exact etiology of plantar fasciitis is unknown in most cases. H owever, multiple risk factors have been associated with plantar fasciitis, particularly obesity, prolonged weight bearing, and limited ankle dorsi exion (De Vera Barredo et al. 2007).
Diagnosing plantar heel pain Plantar fasciitis affects the hindfoot, speci cally the insertion of the plantar aponeurosis at the medial calcaneal tubercle (De Vera Barredo et al. 2007). In some cases, pain under the heel is diagnosed as a heel spur syndrome or plantar heel pain syndrome. H eel spur syndrome refers to the existence of plantar calcaneal spur. H owever, 50–55% of patients with heel pain do not have a calcaneal spur and 15–20% of non-painful heels manifest a spur (Irving et al. 2006, De Vera Barredo et al. 2007). Therefore, the presence of structural pathology (i.e. calcaneal spur) does not correlate necessarily with pain. Plantar heel pain syndrome is, as indicated by its name, a general de nition for the location of pain, but it does not specify the structure of pain origin. Several different structures can be a source of pain under the heel. The plantar surface of the calcaneus serves as an insertion for several 5 16
structures. Structures connected directly to the medial calcaneal tubercle, lateral calcaneal tubercle or adjacent to these tubercles include: short plantar ligament, long plantar ligament, plantar aponeurosis, m. exor digitorum brevis (FDB), m. abductor halluces (AbdH ), m. quadratus plantae (Q P) and m. abductor digiti minimi (AbdDM) (Acland 2010). Therefore, diagnosing plantar heel pain every time as plantar fasciitis is a simpli cation and can often misdirects the treatment. Identifying the speci c source of the pain might be challenging and even in a case where it can be identi ed it does not explain the mechanism leading to pain. Considering the structures in the heel it is reasonable to argue that very different movement patterns of the foot and ankle may cause overloading and sensitization to one of these structures leading to plantar heel pain. For example, constant exion of the toes during weight bearing can potentially cause irritation of FDB, Q P, and AbdH muscle insertions. Constant loading of the lateral arch during weight bearing can potentially lead to overloading of short and long plantar ligaments and AbdDM muscle. Constant medial loading of the foot during weight bearing collapses the longitudinal arches of the foot potentially leading to overstretching of the plantar aponeurosis. All these loading patterns of the foot may become a mechanism resulting in plantar heel pain. Therefore, identifying the movement patterns of the foot and ankle that can potentially lead to overloading and sensitization of the structures is essential when planning and implementing the intervention. O bviously, all the above mentioned examples require different interventions. In addition to symptomatic structures interventions should target the underlying mechanisms that lead to or maintain the plantar heel pain.
Chronic a nkle ins ta b ility Ankle ligament injuries are among the most common musculoskeletal injuries (Pijnenburg et al. 2000, Beynnon et al. 2001, Kerkhoffs et al. 2007). Functional treatment has been recommended for the treatment of ankle ligament injuries since the early nineties (Kannus & Renström 1991, Kaikkonen et al. 1996). The elements of functional treatment include: RICE (rest, ice, compression, elevation), protection of the injured ligament, early weight bearing and exercises (Kaikkonen et al. 1996, Konradsen et al. 2002, van Rijn et al. 2010). H owever, despite functional treatment residual symptoms and disability
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are very common after inversion sprain (Konradsen et al. 2002, van Rijn et al. 2010). After an acute ankle sprain 10–20% of people develop chronic ankle instability (CAI) (de Vries et al. 2006). Two primary causes for CAI are mechanical ankle instability (MAI) and functional ankle instability (FAI) (H ubbard et al. 2007). MAI is de ned as ankle movement beyond the physiological limit of the ankle’s range of motion, whereas FAI is de ned as the subjective feeling of ankle instability (‘giving way’) and/ or recurrent symptomatic ankle sprains (Tropp 2002). It is noteworthy that MAI means objectively measurable movement of the ankle and FAI is a person’s subjective symptoms and disability. MAI and FAI are often seen as dichotomous causes of chronic ankle instability. H owever, recent research has found relationships between MAI and FAI measures. For example, increased anterior laxity correlated with increased dorsi exion strength and increased centre-of-pressure excursions (H ubbard et al. 2007).
Chronic ankle instability and mobility of the ankle Instability as a term refers to increased mobility. By de nition, this is true in MAI when the physiological range of movement is tested passively. O bjective assessment of mechanical ligamentous laxity is often carried out using the anterior drawer test and talar tilt test (H ubbard et al. 2008). H owever, increased mechanical laxity in passive movement testing does not correlate with the functional mobility of the ankle. Similarly, in FAI the subjective feeling of instability, i.e. ‘giving way’, does not mean that functional mobility of the ankle is increased. Based on clinical evidence, patients with CAI often have movement impairments of the ankle. This feature of CAI is often missed. Contrarily to increased mobility, reduced ankle dorsi exion range is known to predict future lateral ankle sprains (de Noronha et al. 2006), whereas generalized joint hypermobility does not increase risk of injury in the ankle region (Pacey et al. 2010).
Chronic ankle instability and pain Pain is a common symptom related to ankle instability (Kannus & Renström 1991, Konradsen et al. 2002, de Noronha et al. 2007). Pain areas vary a lot after initial ankle injury and the pain area may change over time. The different pain areas are often related to the variety of structures that might be involved in inversion sprains,
whereas the change of pain area is thought to indicate multi-tissue involvement (Konradsen et al. 2002). The change of pain area over time may also be related to the person’s behaviour as caused by the injury. After initial injury people adopt, either consciously or instinctively, movement patterns to avoid pain. These movement patterns can be considered protective, that is, an adaptive mechanism to support healing process. H owever, if these movement patterns persist beyond normal tissue healing time they may become pain provocative, that is, maladaptive mechanisms, and result in ongoing pain. Depending on the movement pattern the person has adopted, different areas of the foot and ankle are predisposed to abnormal loading. This might be one explanation for the change of pain area over time after an ankle sprain.
Cognitive proces s es and injury In acute injury, the escape from a harmful situation and the associated withdrawal behaviour promotes healing. In some individuals immediate withdrawal behaviours do not lead to the anticipated reduction of pain, which may be interpreted as a signal of continuous threat. Negative interpretation may not always re ect the real threat and catastrophic misinterpretations of benign physical sensations may occur. Catastrophic interpretations lead to fear reactions. Pain-related fear is likely to cause a cascade of psychological and physical events including hypervigilance, muscular reactivity, avoidance and guarding behaviours and physical disuse, which in turn are responsible for the persistencee of the pain problem (Vlaeyen & Linton 2002). Pain-related fear of movement, or kinesiophobia, has been shown to contribute to disability in foot and ankle patients (Lentz et al. 2010). The contribution of physical factors, pain mechanisms and cognitive factors in CAI is individual and it is unlikely that the same functional treatment is bene cial for all patients with CAI. Therefore, identifying the individual group of factors that are maintaining the patient’s CAI is crucial to planning and implementing an appropriate intervention.
Chronic mus culos keletal oot and ankle dis orders Many foot and ankle pain disorders do not t into existing medical diagnosis categories and, in many 5 17
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cases, even where pathoanatomical diagnosis can be made it does not explain the mechanism leading to the disorder. Examples given earlier in this chapter highlight the need to consider the multifactorial nature of musculoskeletal foot and ankle disorders. Chronic musculoskeletal disorders are particularly challenging as speci c diagnosis is rarely achieved. The tendency for pain and disability to persist in the absence of obvious, ongoing primary peripheral pathology is challenging (Zusman 2002). Therefore, further classi cation of chronic foot and ankle disorders is required. A new classi cation system for chronic musculoskeletal foot and ankle disorders has been proposed (Kangas et al. 2011). This new approach is based on identifying the underlying mechanisms of the disorder. Within a multifactorial bio-psychosocial model, all factors that are maintaining the disorder should be considered. Without the identi cation of these mechanisms, the optimal intervention for the patient’s disorder cannot be determined (Zusman 2002). Chronic pain disorders may change motor control around the foot and ankle region and appear to result in monotonic movement and loading patterns, with speci c parts of the foot and ankle loading unchangingly. Typically, these loading patterns present in a directional manner and are relatively independent of the movement task or activity the patient is performing (Kangas et al. 2011). Identifying the direction of impairment is the basis for identifying the mechanisms involved in movement and motor control-related disorders of the foot and ankle region and for planning and implementing a speci c intervention (Kangas et al. 2011). Maladaptive motor control and movement impairments are considered underlying mechanisms for chronic foot and ankle disorders. Within these impairments, faulty movement patterns and coping strategies result in chronic abnormal tissue loading, pain, disability and distress. Different underlying pain mechanisms of motor control and movement impairments require further subclassi cation. These impairments can present with or without pathoanatomical ndings (O ’Sullivan 2005). In motor control impairments, lack of motor control results in monotonic loading patterns and pain in the foot and ankle. In movement impairments, movement is lost in the direction of pain provocation. In patients with motor control and/ or movement impairments, the patient’s maladaptive movement behaviour is the underlying mechanism 5 18
for the pain. An analysis of all potential factors affecting this movement behaviour should be based on a comprehensive subjective and physical examination and should aim to identify the underlying mechanisms maintaining the chronic foot and ankle disorders. Identifying this underlying mechanism also demands the integration of the proposed classi cation approach for foot and ankle disorders within a clinical reasoning process (Kangas et al. 2011).
Ps yc ho s o c ial fac to rs o f pain and dis ability The inclusion of psychosocial factors in the conceptual framework of pain theory helps to explain the limited association between organic pathology and pain severity (Turk & Wilson 2010). Avoidance behaviour may be reinforcing in the short term through the reduction of distress associated with noxious stimulation. If allowed to persist, it may become a maladaptive response leading to increased fear, limitation of activity, and other physical and psychological consequences that contribute to disability and persistence of pain (Turk & Wilson 2010). Catastrophic interpretations such as the belief that the presence of, or onset of, pain indicates pathology and therefore harm, are thought to contribute to the development of pain-related fear (Turk & Wilson 2010). A theoretical approach to the development of chronic pain and disability is the fear–avoidance model. This model is an attempt to highlight the importance of cognitive and behavioural factors in a chain of events linking the experience of pain to disability. The model stresses the role of catastrophic thinking following the pain experience and the consequent fear and hyper-vigilance. Avoidance behaviour features prominently, largely fuelled by the fear that activity will cause harm and will worsen the pain problem (Boersma & Linton 2006). Fear–avoidance beliefs, catastrophizing, and depression have been identi ed as important psychological variables in the development of a pain problem (Boersma & Linton 2006). The relationship between pain, catastrophizing, depression, fear–avoidance beliefs and function at the individual level is an integrated, interacting, and complex process (Boersma & Linton 2006).
W o rk- re la te d fa c to rs a n d m u s c u lo s ke le ta l fo o t a n d a n kle d is o rd e rs
Psychological variables might operate differently for different people. Therefore, to understand these processes within individuals, there has been a need to identify distinctive patterns of psychological factors (Boersma & Linton 2006). A study by Boersma & Linton (2006) shows that distinct proles of psychological functioning can be extracted and that these pro les are related to development of disability. Fear–avoidance, beliefs and catastrophizing were strongly related. These factors can be, but are not necessarily, accompanied with signs of depression. People in the subgroups ‘painrelated fear’, ‘pain-related fear + depressed mood’, and ‘depressed mood’ reported substantially more functional dif culties and pain and sick leave compared to ‘medium pain-related fear’ and ‘low risk’ subgroups.
Ps ychos ocial actors and neurophys iological pain mechanis ms Pain processing is regulated by different mechanisms that modulate noxious information at the spinal level. This modulation is based on endogenous descending inhibitory and facilitatory pathways that reach the dorsal horn (Weissman-Fogel et al. 2008). It has been proved that these inhibitory pathways are negatively in uenced by catastrophizing (Weissman-Fogel et al. 2008). G rowing evidence is showing that psychological processes have biological effects. For example, cognitive and affective processes within the construct of catastrophizing have been shown to exert an effect on the neuromuscular, cardiovascular, immune and neuroendocrine systems, and the activity in the pain neuromatrix within the brain (Campbell & Edwards 2009). Studies have shown that higher levels of pain catastrophizing correlate with a lower pain threshold, lower pain tolerance, higher pain intensity and greater pain temporal summation (Weissman-Fogel et al. 2008).
Ps ychos ocial actors and mus culos keletal oot and ankle dis orders Pain-related fear of movement has been identi ed as a strong contributor to disability in the foot and ankle (Lentz et al. 2010).
The treatment generally consists of concurrent patient education and encouragement to perform part of an activity of which they are fearful or an activity that is related to this speci c fear. For example, a patient with ankle pain who will not attempt hopping for a distance because of fear of pain in the ankle might be encouraged to begin bouncing on a trampoline or to perform active plantar exion while in one-leg stance. O nce the patient indicates that the fear is reduced, the complexity and dif culty of the task can be progressed in a systematic fashion. The risk factors and consequences of traumatic and non-traumatic lower limb pain are not the same. Traumatic lower limb pain is associated with practising vigorous exercise and a high level of physical tness, while non-traumatic pain is correlated more with psychosomatic symptoms (El-Metwally et al. 2006). G reater numbers of depressive symptoms have been found to associate with greater impairment in lower extremity functioning (McDermott et al. 2003).
Life s tyle fac to rs and mus c ulo s ke le tal fo o t and ankle dis o rde rs Lifestyle factors, such as obesity, have been related to foot and ankle pain disorders (Irving et al. 2006, G aida et al. 2010). There is evidence of an association between increased body mass index and chronic plantar heel pain (Irving et al. 2006). Achilles tendon pathology is associated with central fat distribution among men and with peripheral fat distribution among women (G aida et al. 2010).
Wo rk-re late d fac to rs and mus c ulo s ke le tal fo o t and ankle dis o rde rs Jobs that necessitate prolonged standing and walking activities are commonly associated with worker’s complaints of foot and ankle pain. The foot and ankle area has been identi ed as the most frequently affected body region among salespersons in department stores (Pensri et al. 2010). Prolonged standing is associated with foot and ankle symptoms among salespersons (Pensri et al. 2010). Furthermore, 5 19
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prolonged standing has been associated with the occurrence of chronic plantar heel pain (Irving et al. 2006). Increased time spent walking is associated with foot and ankle disorders among assembly plant workers (Werner et al. 2010).
Subje c tive e xaminatio n In the assessment of the foot and ankle disorders the physiotherapist needs to consider the multifactorial nature of the musculoskeletal disorders. Subjective examination forms a basis for the clinical reasoning process. Therefore, thorough subjective examination is required to consider all dimensions of the disorder. The aim of the subjective examination is to gather information about the patient’s disorder from the patient’s perspective. Therefore, the communication style should re ect empathy, respect and understanding to create a con dent atmosphere for the patient. A therapeutic relationship with the patient can be formed through mindful interviewing. The patient’s story may re ect that psychosocial factors are contributing to their foot and ankle disorder. The role of these factors is individual. Therefore, it is reasonable to use standardized questionnaires to screen these factors. For example, the Ö rebro musculoskeletal pain questionnaire (Ö MPQ ) can be used for screening for ‘yellow ags’. The Tampa scale of kinesiophobia (TSK) has been used to determine the in uence of pain-related fear of movement on foot and ankle disability (Lentz et al. 2010). The subjective examination can be carried out in a structured manner or more informally. When the subjective examination is carried out in a structured manner it helps the physiotherapist to gather the most relevant information concerning the patient’s symptoms. A structured interview is suitable for obvious problems such as acute ankle sprain. Furthermore, some patients may nd it easier to talk about their disorder when questioning is well organized. H owever, if the interview is too strictly organized a lot of information might be lost. Therefore, the more informal interview has some advantages and it is more suitable, for example, in chronic foot and ankle disorders. It gives freedom to patient to explain their problem and how they experience it. The way patients describe their problem is often very informative because it includes information of factors in uencing a patient’s pain and movement behaviour. For example, a patient 520
might experience that the symptom itself is not the main problem, but the disability resulting from the symptom is the most disturbing problem. This disability might be maintained with maladaptive thoughts and beliefs. The challenge of an informal interview is to gather the relevant information that the patient possesses, but does not spontaneously reveal. This information can be obtained with re ective and follow-up questioning. The informal interview is best conducted by an experienced physiotherapist and it is not always suitable. As authorities, we have to be aware that our questioning is sometimes directing the patient’s attention and providing a structure for the patient to make observations about the problem. Therefore, our questioning should not reinforce the problem, but should be aiming towards recovery from the very beginning. The interview is the beginning of the management. The following description of the subjective examination of the foot and ankle patient is in a structured format. Clinically, the same information can be gathered in any order. It is the physiotherapist’s responsibility to nd the most con dent way of accomplishing the patient’s interview.
Kind o dis order The rst question aims to establish what the patient’s main problem is. In other words, what brings the patient to physiotherapy and what is the patient seeking from physiotherapy? The answer to the rst question is recorded in the patient’s own words on the body chart. Information from ‘Q uestion 1’ aids in the establishment of the kind of disorder. Many patients with musculoskeletal foot and ankle disorders will present with pain as the main problem. O ther typical symptoms are stiffness, ankle sprains and ‘giving way’. H owever, it is noteworthy that some patients do not experience the symptom as a main problem, but disability, i.e. loss of function resulting in activity limitation. We should not assume that a symptom is the disability or that a symptom alone is causing the disability. H ypotheses generation begins from the answer to ‘Q uestion 1’. For example, a patient may reply to the rst question: ‘I twisted my left ankle two weeks ago and it’s still swollen and painful when I walk’. This information immediately reveals the symptom area and possible local structural source of the symptoms. The answer includes information
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about the activity that provokes the symptoms. Early hypotheses of the pain mechanisms can be generated from this information. Furthermore, walking is the activity that is affected. The answer is also providing the rst information about the injury mechanism and a stage of tissue healing. The physiotherapist may even generate an early hypothesis for treatment and a prognosis based on the answer to ‘Q uestion 1’. Four different clinical pro les are presented in this chapter. The rst clinical pro le is typical of a somatic source of symptoms. Somatic symptoms arise from a bone, ligament, joint or muscle. The second clinical pro le is more related to chronic, local symptoms where the patient’s maladaptive behaviour maintains the disorder. In the third clinical pro le typical features of radicular pain and neuropathy are represented. The fourth clinical pro le represents foot and ankle disorder with central sensitization.
Symptom area(s ) The main question under symptom area is: where are the symptoms? In addition to location of the symptom(s), each symptom area is further de ned according to quality, frequency and depth of the symptom(s). Detailed topographical anatomy knowledge is required to align local symptoms with recognizable structures in the foot and ankle region. In the case of local foot and ankle symptom(s) where a patient can easily pinpoint the area, and describe the type of pain, a speci c structural source may be hypothesized. Super cial pain is often related to soft tissue or neural structures, whereas deep pain is often related to articular structures. Symptoms that are consistently related to mechanical stimulus with the sensation most likely linked to stimulus intensity, indicate peripheral nociceptive pain. These local symptoms may be associated with stiffness. The presentation of stiffness is consistently related to movement direction(s) and it can be associated with or without pain. In some cases local foot and ankle symptom(s) do not correspond with the course of any single anatomical structure and a patient may have difculty in de ning the symptom area exactly. Pain may be associated with other symptoms like a feeling of loss of control or stiffness. Furthermore, the patient may describe symptoms with other
than physical qualities, for example, frustration, fear and anxiety. Symptoms are often related to loading of the foot and ankle, but the relationship between stimulus intensity and sensation may be inconsistent. Stiffness is related to pain or anticipation of pain. These local symptoms may indicate peripherally mediated pain associated with factors other than physical factorsrelated to central pain mechanisms. Foot and ankle symptom(s) may originate from remote structures. A good knowledge of neuroanatomy is needed to differentiate between typical innervation areas of the nerves supplying thefoot and ankle region and somatic structures. For example, the pain around the medial forefoot may arise from the rst MTP joint, constant loading of that region without speci c structural ndings or the L5 nerve root. H owever, the neurogenic symptoms vary greatly depending on the local structure involved and the disorder. The symptoms differ depending on the pathophysiology related to the nerves. Radiculopathy, conduction block of the spinal nerve or its root, results in numbness or weakness. Radiculopathy alone does not cause pain. In radicular pain that arises as a result of irritation of the spinal nerve or its roots, pain is shooting and band-like. Radicular pain may occur with or without radiculopathy (Bogduk 1997). In a neuropathy, symptoms related to sensory innervation include sensory loss, dysaesthesia and/ or paraesthesia. Dysaesthesia includes symptoms like burning, pricking, tingling, cramping and throbbing. The most typical presentation of paraestheasia is spontaneous tingling that is often described as pins and needles. It is important to realize that numbness and increased sensitivity may be at the same site. The neuropathic process involving motor nerves will result in muscle wasting and weakness (Bennett 2006). Foot and ankle symptoms relating to radicular pain or neuropathy are often spontaneous and/ or variable, but independent from foot and ankle loading. Sometimes a patient presents with widespread pain at the foot and ankle. The patient might describe the main symptom area as migrating and the type of pain as vague, worrying and severe. Pain is constant and variable, but loading makes it worse and most activities increase the symptoms. Pain may be associated with psychosocial factors relating to fear, catastrophizing and depression. These symptoms may indicate a dominant central pain mechanism. 521
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Behaviour o the s ymptom(s ) The main question in behaviour of the symptom is: what makes the symptoms worse and/ or better? In the case of local foot and ankle symptom(s) with nociceptive pain, symptoms are provoked with activities involving foot and ankle loading and movements. Typical activities are standing, walking, running and jumping. O ften pain is closely related to certain activities and the intensity of pain correlates with the amount of mechanical stress and vice versa – pain is often diminished by avoiding the particular activity. Among athletes and dancers foot and ankle pain may be provoked only during strenuous foot and ankle movements or during the great number of repetitions required in sports and dance. H owever, it is important to realize that mimicking movement patterns may be repeated during normal daily activities. In the acute stage of in ammation pain may be easily provoked, and it may linger after provocation. In the case of local foot and ankle symptoms with peripherally mediated pain and associated psychosocial factors, symptoms are still provoked with activities of foot and ankle loading and movements. H owever, the intensity of pain does not necessarily correlate with the amount of mechanical stress. A patient may describe many activities with unequal mechanical stress that provoke the same pain. Analysing the activities the patient is describing may reveal that they all include the same movement direction of the foot and ankle. For example, the patient may say that walking down the stairs, the propulsion phase of walking and squatting are provoking the same pain. All these activities include dorsi exion of the ankle and this may be the connecting movement component. Furthermore, the patient may discover that avoiding provoking activities does not resolve the disorder. This is often because of the dif culty in recognizing pain triggers or the impossibility of avoiding provoking the movement component during normal daily activities. In radicular and neuropathic foot and ankle pain symptoms are inconsistently related to foot and ankle loading and movements apart from muscle weakness. Instead, radicular foot and ankle pain is often related to impairments and loading of the low back. In foot and ankle neuropathies symptoms are often spontaneous or the responses to movement stimulation are abnormal. In the 24-hour behaviour 522
of symptoms, patients often complain of night pain. Changing positions or gentle moving like slow walking may diminish the symptoms. In the case of widespread foot and ankle symptoms and dominant central sensitization, pain may be related to foot and ankle loading and movements, but the stimulus–response relationship is distorted. Response to different stimuli is unpredictable and inconsistent. Similarly, something that diminishes symptoms today may not ease them off tomorrow.
Behaviour o the patient according to the dis order The main question in this phase of the subjective examination is: how does the patient manage with the problem? The aim of this question is to establish the patient’s coping strategies according to the disorder. This question is open and directs the attention to psychological effects of the disorder instead of concentrating only on the symptoms. The patient may have a belief that pain always indicates pathology and therefore harm. This will often lead to avoidance of activities that provoke or that the patient expects to provoke the symptoms. Note, in particular, if the patient is describing activities which provoke the symptoms and if they is avoiding these activities. This may re ect catastrophic thinking and avoidance behaviour and result in disability and impaired physical performance.
His tory o the s ymptoms The main questions at this stageare: when and how did the symptoms start? In the case of local somatic foot and ankle symptoms with nociceptive pain, the onset of symptoms is often identi able. The onset may be related to trauma or an event. In cases of trauma, the progression of symptoms is compared with expected tissue healing time. Multiple symptom areas within the same foot may indicate involvement of more than one structure. For example, after an inversion sprain a variety of structures might be injured. Recognizable events are often related to so called ‘use categories’. ‘Use categories’ include: over-, mis-, dis-, ab-, new- and non-use. Patients are not always aware of these events and the beginning of the symptoms. Therefore, it is sometimes useful to ask: did you do something unusual when the
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symptoms started? Among athletes and dancers changes in training and choreography and training environment may play a crucial role in the onset of symptoms. In the case of local foot and ankle symptoms with peripherally mediated pain and associated psychosocial factors, symptoms persist over the expected tissue healing time or without identi ed structural pathology. Typically, symptoms start either gradually without an identi ed event, or after a trauma, but the symptoms and disability do not correlate with the mechanism of injury. Sometimes a patient may recall an old, mild injury after which the foot and ankle has not been symptom free. The main line of thought here is that the relationship between present symptoms and disability cannot be explained by any single factor in the past. The onset of radicular foot and ankle pain is often associated with the onset of low back pain and related movement impairment. The most common cause of radicular pain is disc herniation (Bogduk 1997). Therefore, the progression of radicular foot and ankle pain often follows the course of low back pathology and associated symptoms. The history of neuropathic foot and ankle pain is variable. Neuropathic pain can become apparent immediately following injury or be delayed for months or years. Sometimes neuropathic pain is triggered by a second injury at the same area. Widespread foot and ankle symptoms with dominant central sensitization may develop after a trauma, surgery, immobilization or prolonged over-use.
His tory o the patient’s behaviour according to the dis order The main question at this stage of the subjective examination is: how has the patient managed with the problem since it started? With this question the therapist aims to identify the strategies the patient has used to cope since the beginning of the disorder. This stage should particularly focus on the psychological process involved in pain perception and behaviour and the attention and attributes the patient gives to noxious stimuli, coping strategies and behaviour (Linton 2002). This information is crucial to understanding the patient’s behaviour according to the disorder and for determining if the patient’s coping strategies will promote healing and recovery or reinforce the disorder.
Medical s creening ques tions These questions are for the screening of possible precautions and contraindications relating to physical examination and treatment. Q uestions concerning the patient’s general health, medication, diagnosed diseases and medical screenings should be asked routinely. With the foot and ankle ankle region particular care should be taken, for example, with diabetic patients. Sensorimotor neuropathy and vascular insuf ciency may predispose to infections in the diabetic foot (Powlson & Coll 2010).
Planning the phys ic al e xaminatio n Planning the physical examination is a critical part of the clinical reasoning process. It is crucial for novice physiotherapists to plan the phases of of the physical examination; however, it is also important for experienced physiotherapists to do this, especially in cases where information from the subjective examination indicates a complex foot and ankle disorder. O ne phase of planning of the physical examination is expressing hypotheses in different categories. Information within these categories is changing through research. Therefore, it is important for all physiotherapists to update the planning process from time to time. This enables the application of new knowledge into the clinical reasoning process. Planning the physical examination includes three phases: re ection on the subjective examination, expressing hypotheses and planning physical examination procedures.
Re ection on the s ubjective examination In ref ection on the subjective examination the physiotherapist veri es that the subjective examination provides suf cient information to direct the physical examination and the extent of examination. Furthermore, the main ndings have to be measurable for reassessment in subsequent sessions.
Expres s ing hypothes es categories Expressing hypotheses categories explicitly helps the physiotherapist to identify all the relevant factors 523
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related to the disorder. This helps the physiotherapist to direct the physical examination. In the foot and ankle region several hypotheses categories are required to direct the physical examination and the subsequent intervention. Each category has consequences for the examination process and treatment. These hypotheses categories are: 1. 2. 3. 4. 5. 6. 7. 8.
Nature of the disorder Source of the symptoms Neurophysiological pain mechanisms Direction of the impairment Contributing factors Intervention Precautions and contraindications Prognosis.
Na ture of the d is ord e r The nature of the musculoskeletal foot and ankle disorder is multifactorial. The term disorder contains the physical and psychosocial factors related to disorder and their effects (Elvey & O ’Sullivan 2004). For example, inversion sprain of the ankle may result in the rupture of the anterior talo bular ligament (ATFL). This represents the pathology of the disorder. The physical effect of this is that the patient cannot do plantar exion of the ankle because of the pain. Injury and resulting pain is always accompanied by psychosocial factors. Pain is psychologically processed and it will in uence the patient’s behaviour. These effects are considered as psychological effects. Impairments of movement are consequences of physical and psychosocial factors related to the disorder. For an impairment of movement to be relevant it has to be in the context of the nature of the disorder.
Sourc e of the s ymp toms In musculoskeletal foot and ankle disorders local sources of the symptoms and impairments include somatic structures, i.e. a bone, a joint and a muscle. Peripheral nerves in the foot and ankle region can also be included in this subcategory. The lumbar spine is the most typical remote source causing radicular symptoms in the foot and ankle region. H owever, in many cases a speci c source of the foot and ankle symptoms cannot be identi ed. Then the source of the symptoms is ‘non-speci c’. This does not mean that the impairment or disorder is ‘non-speci c’. 524
Ne urop hys iologic a l p a in me c ha nis ms Pain mechanisms can be divided into peripheral and central mechanisms. This separation is somehow arti cial, because different pain mechanisms are always overlapping. H owever, in a clinical situation it is convenient to think about the mechanism that is dominating in the patient’s disorder. The peripheral pain mechanism can be further divided into the nociceptive pain mechanism and the peripheral neurogenic pain mechanism. These mechanisms are both related to pain states where the source of the symptom and/ or pathophysiological processes can be identi ed. The third peripheral mechanism is peripherally mediated pain where the speci c source of the symptoms is not always identi ed. Disorders with peripherally mediated pain are often associated with psychosocial factors. The central pain mechanism can be further divided into two central subcategories. In the rst subcategory psychosocial factors play a dominant role and a psychiatric disease can be diagnosed. In the other subcategory psychosocial factors do not play a dominant role, but the central nervous system is physiologically sensitized. All these pain mechanisms require a different approach in the examination and treatment of the disorder. Pain mechanisms are explained in detail in Jones (2014), Blake & Beames (2014).
Dire c tion of the imp a irme nt This hypotheses category aims to clearly de ne the direction of impaired movement in the disorder. For an impairment of movement to be relevant it should present in the direction of the pain. Movement may be lost or movement or loading increased in a speci c direction. The direction of the impairment may be related to physical or psychological effects of the disorder. For example, after an acute inversion sprain the direction of the impairment correlates with structural pathology related to injury, whereas, in more chronic disorders the direction of the impairment is related to loading patterns of the foot and ankle. Both motor control and movement impairments of the foot and ankle present in a directional manner (Kangas et al. 2011).
Contrib uting fa c tors Contributing factors of the disorder include biomechanical factors (e.g. structural malalignment of
P h ys ic a l e xa m in a tio n
the forefoot), lifestyle factors (e.g. obesity), social factors (e.g. work community) and environmental factors (e.g. training shoes and/ or terrain).
Inte rve ntion Intervention is a term used to embrace manual therapy procedures of treatment and strategies of management. Treatment is regarded as speci c intervention performed by the clinician. Management is intervention performed by the patient under the direction or by the prescription of the clinician (Elvey & O ’Sullivan 2004). Within this hypotheses category, hypotheses are generated relating to the need for treatment procedures and management strategies. For example, in motor control impairments of the foot and ankle, management strategies (i.e. exercise intervention) is the primary approach, whereas with movement impairments restoring normal physiological range of movement of the foot and ankle often requires speci c treatment (i.e. mobilization or manipulation) before exercise intervention is initiated.
P re c a utions a nd c ontra ind ic a tions Within this hypotheses category, hypotheses are generated in two directions. The rst direction considers the possible need for cautious examination and/ or a need for immediate referral to medical care in thecase of serious pathology, i.e. a ‘Red Flag’. The second direction considers the indication for manual therapy intervention and whether a manual therapy intervention has the ability to favourably in uence a disorder towards recovery (Elvey & O ’Sullivan 2004). For example, in tibialis posterior tendon insuf ciency therapeutic exercise may be helpful if the tendon is not ruptured, but in the case of tendon rupture surgery is warranted.
P rognos is The prognosis can be thought of as a summary of the previous categories. In each hypotheses category the features that are favourable or not favourable to recovery are compared and contrasted. O bviously, the patient with more features favourable to recovery will have a better prognosis. For example, acute trauma with identi ed pathology and adaptive response of the patient without contributing factors are features that are favourable to recovery.
Planning phys ical examination procedures After expressing hypotheses the physical examination procedure is planned. The physical examination has to consider all dimensions related to the disorder. The physical examination aims to prove or disprove the working hypotheses.
Phys ic al e xaminatio n After the subjective examination and the planning of the physical examination the physiotherapist has hypotheses of the various factors related to the disorder. Physical examination of the foot and ankle should be performed in the context of the disorder. During the physical examination the physiotherapist should con rm the generated hypotheses. Furthermore, the physical examination provides information about the physical factors related to the disorder, the behaviour of the symptoms during the examination and the patient’s pain and movement behaviour. The physical examination of the foot and ankle can be divided into phases. These phases are represented in Table 9.1 (Kangas et al. 2011). Each phase of the examination serves a purpose in completing a pro le of the patient’s foot and ankle disorder.
Obs ervation in non-weight bearing The physical examination begins with general observation of the foot and ankle. Any signs of injury, in ammation, colour changes of the skin or atrophy/ hypertrophy of the muscles are noted. After that, observation of the foot and ankle continues in two different conditions: in non-weight bearing (n-WB) and weight bearing (WB). O bservation in n-WB is carried out with the foot and ankle in standard position. The STJ neutral position provides a clinically useful method for mid-positioning of the foot and ankle (Elveru et al. 1988). From this position, the structural morphology of the foot and ankle is examined. Structural malalignments of the foot are measured. For example, malalignments of the forefoot are typical ndings and they may be important contributing factors for the pain disorder. Furthermore, changes like asymmetric wearing of the calcaneal fat pad and thickened plantar skin may re ect the loading pattern of the foot and ankle. Palpation of 525
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the plantar surface of the foot may reveal increased sensitivity and re ect the direction of the loading pattern.
Obs ervation in weight bearing The second phase of the observation is is carried out in WB (Fig. 9.3). This phase of the examination re ects how the foot and ankle is orientated under WB. This does not necessarily correlate with n-WB position. For example, a patient with a exible at foot will have a normal arch under n-WB conditions, but a substantial loss of arch height under WB conditions (Young et al. 2005). Furthermore, structural malalignments of the foot are compensated in WB conditions, but compensatory mechanisms are variable. It is crucial to identify the individual compensatory mechanisms in order to understand the contribution of malalignment to the patient’s disorder. The WB position is always compared to the n-WB position. This will reveal whether the WB position of the foot and ankle is in uenced by the changes in structural morphology or whether it is related to functional factors and will directly in uence the planning and implementing of the intervention. The patient with
Fig ure 9.3 • Patient in standing position on a podogram.
unusual structural changes may require foot orthoses, whereas the patient with a more functional disorder will bene t from the therapeutic exercise as a primary intervention. Furthermore, the contact areas of the foot provide information about the WB structures and indicate the direction of foot and ankle loading. H owever, it is crucial to understand that the structural position of the foot and ankle does not correlate directly with the function of the foot and ankle (Kaufman et al. 1999).
Functional tes ts The next phase of the examination is functional tests. These tests are simple functional movements or activities that will re ect the function of the foot and ankle during movements, the behaviour of the symptoms and the patient’s pain and movement behaviour during tested movements. This will provide relevant information concerning the physical and psychological factors related to the disorder and their effects. O ne special functional test is functional demonstration. The functional demonstration is a movement that the patient experiences relevant to the disorder. It may be a movement that reproduces the patient’s symptoms and patient experiences as ‘abnormal’ or somehow dif cult or challenging. The functional demonstration is often very informative, because it re ects the patient’s individual experience of the movement disorder. If the functional demonstration is reproducing the patient’s symptoms the test may be used for differentiation between musculoskeletal structures to establish the source of the symptoms. The functional demonstration may be used to identify the functional impairment and the speci c direction of the impairment. Furthermore, functional demonstration will direct the intervention. Functional demonstration may be the most relevant movement and/ or activity for the patient to normalize. This may mean that part of the intervention is carried out in functional demonstration conditions. The routine of functional tests begins with one-leg standing. In standing on one leg, the position and loading direction of the foot and ankle, contact areas of the foot, the patient’s ability to control the balance and their response to the situation are observed. During squatting, the ankle range of motion, quality of movement and symptom response to 527
C H AP TE R 9
Manag e me nt o f fo o t and ankle dis o rde rs
ankle dorsi exion are examined. Furthermore, the contact areas of the foot and loading direction of the foot and ankle during movement are observed. The same parameters are examined and observed during rising on the forefoot. During movements the patient’s pain and movement behaviour are observed. Avoidance of movement may indicate movement impairment. Unawareness of the loading pattern may indicate motor control impairment. Repeating the same tests on one leg will often exaggerate existing impairments and behaviours. If a directional pattern of functional impairment is emerging other tests may be used to assess the consistency of the movement behaviour. For example, jumping and landing, walking up and down the stairs, walking backwards and sport- or dancespeci c movements may be used as functional tests. Furthermore, the patient’s ability to activate the forefoot independently, control the neutral position of the hindfoot and dissociate forefoot and hindfoot control may be used to assess the patient’s ability to control movement of the foot and ankle.
Obs ervation o gait O bservation of the gait provides one special feature for the physical examination of the foot and ankle. This feature is the timing relationship of the movements during the gait cycle (Perry 1992). This knowledge may be used to observe the patient’s movement behaviour and con rm the ndings from functional tests. For example, a patient with a lateral loading pattern of the foot will be missing normal pronation during loading response and contact of the medial forefoot during terminal stance and preswing. In another example, a patient with movement impairment of the ankle in dorsi exion will have dif culties during late mid-stance and early terminal stance. The compensations for the missing dorsi exion are most likely to be seen during these phases of the cycle.
Active movements The next phase of the examination is active movements of the foot and ankle. In this phase active movements are examined either in supine or prone lying. In supine lying active movements may be used for isometric muscle tests and tendon tests. These tests may provide information concerning the source of the symptoms and the effects of the disorder. 528
Furthermore, active movements may be used to examine the patient’s ability to dissociate movements between hindfoot and forefoot and between forefoot and toes. This may con rm the hypotheses concerning the direction of the impairment. In prone lying active movements may be used to examine the active range of motion, quality of active movement and symptom response to active movement. The patient’s pain and movement behaviour are observed during active movements. This precedes passive movement testing.
Pas s ive movements Passive movement testing of the foot and ankle is performed in a sequential manner. This sequence is presented in Figure 9.4. Passive movement testing may be used for provocation testing of the foot and ankle joints. Furthermore, passive movement testing aims to identify movement impairments and the direction of the impairment. It may provide further information of the mechanisms underlying the impairment.
Provocation tes ts The last phase of physical examination contains provocation tests for other structures in the foot and ankle region, screening tests for other body regions and neurological and vascular screening tests. O ther musculoskeletal structures are, for example, neural tissue. The examination of neural tissue is explained in detail in other sources (Butler 2000). Screening tests for other body regions may include the knee, hip, lumbar spine and thoracic spine. Neurological screening is warranted if the patient has any signs indicating changes in the conduction property of the nerves. Vascular screening tests should be performed routinely with diabetic patients.
Tre atme nt te c hnique s Examination of passive foot and ankle movements follows the sequence presented in Figure 9.4. In the examination sequence movements begin from the physiological movements of the whole foot and ankle. After that physiological movements are carried out separately for the forefoot or hindfoot. Forefoot and hindfoot movements are further divided into single-joint movements with accessory
Tre a tm e n t te c h n iq u e s
Passive Movement Testing and Joint Provocation Testing of the F&A
Passive Physiological Movements of the F&A: DF, PF, PRO, SUP
PRO and SUP represent a triplanar movements of the F&A Components of PRO: in HF are DF, EV and LR and in FF are DF, EV and ABD
Sy provocation, stiffness, movement impairment
Components of INV: in HF are PF, INV and MR and in FF are PF, INV and ADD
The first differentiation is done between the movements of the hindfoot (HF) and the forefoot (FF)
HF Passive Physiological Movements: DF, PF, PRO, SUP
FF Passive Physiological Movements: DF, PF, PRO, SUP
Sy provocation, stiffness, movement impairment
Sy provocation, stiffness, movement impairment,
The next differentiation in HF is done between individual joints of the ankle
The next differentiation in FF is done between physiological movements of the transversejoint rows and longitudinal rays
Passive Physiological MR/LR, INV/EV and accessory movements of thedist.tib/fib, TCJ and STJ
Sy provocation, stiffness, movement impairment
The next phase of differentiation is done between individual joints of the transversejoint rows and longitudinal rays
Accessory movements of the individual joints of the transverse rows and longitudinal rays
Fig ure 9.4 • Sequential passive movement testing.
movements. This sequence enables the therapist to identify the impaired physiological movement direction and localize the impairment to a speci c joint and specify the direction of the most relevantly impaired accessory movement within the impaired
physiological range of movement. This process will provide the information required to determine the direction and intensity of the passive treatment technique. All passive movements used for examination can be applied as treatment techniques either 529
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independently or as combined physiological and accessory movements. Therefore, the possible combinations are numerous. In text that follows, the treatment techniques most frequently used by the author in daily clinical practice are described.
Pas s ive phys iological movements o the oot and ankle The rst phase of passive movement examination is the physiological movements of the whole foot and ankle. The physiological movements are plantar exion (PF), dorsi exion (DF), supination (Sup) and pronation (Pron).
P la nta r e xion (Fig. 9.5) • Direction: Plantar exion of the foot and ankle. • Symbol: PF. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee, the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand holds the heel: the thumb around
Application of forces by therapist (method) • The movement is produced by simultaneous and equal action of both arms. The left arm moves downwards and the right arm upwards.
Dors i e xion (Fig. 9.6) • Direction: Dorsi exion of the foot and ankle. • Symbol: DF. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee, the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand holds the heel from behind, with the thumb along the lateral surface and the ngers along the medial surface of the heel. • The right hand is placed over the plantar surface of the metatarsals, the thumb over the lateral surface and the ngers over the medial surface of the forefoot.
Application of forces by therapist (method) • The movement is produced by simultaneous and equal action of both arms. The left arm moves upwards and right arm downwards.
the lateral surface, the ngers around the medial surface. • The right hand is placed over the dorsal surface of the metatarsals, the thumb over the lateral surface and the ngers over the medial surface of the forefoot.
Sup ina tion (Fig. 9.7)
Fig ure 9.5 • Plantar exion.
Fig ure 9.6 • Dorsi exion.
530
• Direction: Supination of the foot and ankle. • Symbol: Sup.
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transverse plane movements the previous components are maintained.
P rona tion (Fig. 9.8) • Direction: Pronation of the foot and ankle. • Symbol: Pron. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee, the right knee on the couch to support the patient’s left shin. Fig ure 9.7 • Supination.
• Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee, the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • For the plantar exion component, the left hand holds the heel with the thumb around the lateral surface and the ngers around the medial surface. • The right hand is placed over the dorsal surface of the metatarsals, the thumb over the lateral surface and the ngers over the medial surface of the forefoot. • After plantar exion, the left hand moves behind the heel simultaneously maintaining the plantar exed position of the hindfoot. Changing the grip is a prerequisite for introducing inversion and medial rotation movements.
Localization of forces (position of therapist’s hands) • The left hand holds the heel from behind with the thumb along the lateral surface and the ngers along the medial surface of the heel. • The right hand is placed over the plantar surface of the metatarsals, the thumb over the lateral surface and the ngers over the medial surface of the forefoot.
Application of forces by therapist (method) • The pronation movement begins with dorsi exion (i.e. sagittal plane movement). Both arms move simultaneously and equally to produce the dorsi exion movement. While maintaining dorsi exed position, the foot and ankle is moved into eversion (i.e. frontal plane movement). The last components of pronation are the lateral rotation of the hindfoot and abduction of the forefoot (i.e. transverse plane movement). While doing the transverse plane movements the previous components are maintained.
Application of forces by therapist (method) • The Sup movement begins with plantar exion (i.e. sagittal plane movement). Both arms move simultaneously and equally to produce the plantar exion movement. While maintaining the plantar exed position the grip is changed. After that the foot and ankle are moved into inversion (i.e. frontal plane movement), with both hands working simultaneously and equally. The last components of the supination movement are the medial rotation of the hindfoot and adduction of the forefoot (i.e. transverse plane movement). While doing the
Fig ure 9.8 • Pronation. 531
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• In general, supination and pronation movements are stressing the foot and ankle in all three planes of the movement. The order of movement components described above represents the routine examination sequence. H owever, the order of movements may be changed if it is relevant for the patient’s disorder. For example, the patient may present with a pain-provoking movement pattern where the dominant movement component of the hindfoot appears in eversion (i.e. in frontal plane) and in the forefoot in abduction (i.e. in transverse plane). In such a case, it may be useful to combine simultaneously these movement components in passive movement examination. • If physiological movements of the whole foot and ankle reproduce the patient’s symptoms or reveal impaired movements, examination is continued. The next phase of examination is passive physiological movements of the hindfoot and forefoot separately. If the hypothesis is that the movements of the hindfoot are relevant to the patient’s disorder, it is reasonable to begin from the physiological movements of the hindfoot. H owever, it is equally important to examine the forefoot to prove that the passive physiological movements of the forefoot are not relevant to the patient’s disorder.
Pas s ive phys iological movements o the hind oot
Fig ure 9.9 • Plantar exion of the hindfoot.
• Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee, the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand holds the heel: the thumb is around the lateral surface and the ngers around the medial surface. • The right hand is placed over the dorsal side of the head and neck of the talus, the thumb over the lateral surface and the index nger over the medial surface of the neck of the talus.
The movements of the hindfoot involve three joints: the distal tibio bular joint, TCJ and STJ. The movements of the forefoot involve the MTJ, intertarsal joints, tarsometatarsal joints and intermetatarsal joints.
Application of forces by therapist (method)
P la nta r e xion of the hind foot (Fig. 9.9)
Dors i e xion of the hind foot (Fig. 9.10)
Plantar exion of the hindfoot is basically the same movement as the plantar exion of the whole foot and ankle. The only difference is that the movement is localized to the hindfoot. Therefore, the distal right hand is placed on the dorsal side of the head and neck of the talus adjacent to the ankle. The forefoot will follow the movement, but there is no stress on forefoot structures.
• For the dorsi exion of the hindfoot, the distal
• Direction: Plantar exion of the hindfoot. • Symbol: H indfoot PF. 532
• The movement is produced by simultaneous and equal action of both arms. The left arm moves downwards and the right arm upwards.
• • • •
right hand is placed over the plantar surface of the distal calcaneus. Direction: Dorsi exion of the hindfoot. Symbol: H indfoot DF. Patient starting position: Prone, 90° knee exion. Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
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• Direction: Supination of the hindfoot. • Symbol: H indfoot Sup. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand holds the heel: the thumb is Fig ure 9.10 • Dorsi exion of the hindfoot.
Localization of forces (position of therapist’s hands) • The left hand holds the heel from behind with the thumb along the lateral surface and the ngers along the medial surface of the heel. • The right hand is placed over the plantar surface of the distal calcaneus, the thumb over the lateral surface and the index nger over the medial surface of the heel and talus.
Application of forces by therapist (method) • The movement is produced by simultaneous and equal action of both arms. The left arm moves upwards and the right arm downwards.
Sup ina tion of the hind foot (Fig. 9.11) For the supination of the hindfoot, the distal right hand is placed on the dorsal side of the head and neck of the talus adjacent to the ankle.
around the lateral surface and the ngers around the medial surface. • The distal right hand is placed on the dorsal side of the head and neck of the talus adjacent to the ankle. • After plantar exion, the left hand moves behind the heel simultaneously maintaining the plantar exed position of the hindfoot. Changing the grip is a prerequisite for introducing inversion and medial rotation movements. The right hand turns towards the left hand. The thumb of the right hand holds the talus laterally and the index nger holds the talus medially.
Application of forces by therapist (method) • The supination movement begins with plantar exion (i.e. sagittal plane movement). Both arms move simultaneously and equally to produce the plantar exion movement. While maintaining the plantar exed position the grip is changed. After that the hindfoot is moved into inversion (i.e. frontal plane movement) with both hands working simultaneously and equally. The last component of the supination movement is the medial rotation of the hindfoot (i.e. transverse plane movement). While doing the transverse plane movements the previous components are maintained.
P rona tion of the hind foot (Fig. 9.12) For the pronation of the hindfoot, the distal right hand is placed over the plantar surface of the distal calcaneus.
• Direction: Pronation of the hindfoot. • Symbol: H indfoot Pron. • Patient starting position: Prone, 90° knee Fig ure 9.11 • Supination of the hindfoot.
exion. 533
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Pas s ive phys iological movements o the ore oot For the examination of the independent forefoot movements, the hindfoot is maintained in neutral position. Therefore, the proximal hand is used to xate the hindfoot while the distal hand produces the physiological movement for the forefoot.
P la nta r e xion of the fore foot (Fig. 9.13) For the plantar exion of the forefoot the proximal left hand is placed over the plantar surface of the calcaneus.
• Direction: Plantar exion of the forefoot. • Symbol: Forefoot PF. • Patient starting position: Prone, 90° knee
Fig ure 9.12 • Pronation of the hindfoot.
exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand holds the hindfoot in neutral • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand holds the heel from behind with the thumb along the lateral surface and the ngers along the medial surface of the heel. • The right hand is placed over the plantar surface of the distal calcaneus.
position. The distal right hand is placed over the dorsal surface of the metatarsals with the thumb over the lateral surface and the ngers over the medial surface of the forefoot.
Application of forces by therapist (method) • Movement is produced with the right arm moving upwards. The left arm is producing a counterforce downwards to maintain the position of the hindfoot.
Application of forces by therapist (method) • The pronation movement begins with dorsi exion (i.e. sagittal plane movement). Both arms move simultaneously and equally to produce the dorsi exion movement. While maintaining the dorsi exed position, the hindfoot is moved into eversion (i.e. frontal plane movement). The last component of the pronation movement is the lateral rotation of the hindfoot (i.e. transverse plane movement). While doing the transverse plane movements the previous components are maintained. 534
Fig ure 9.13 • Plantar exion of the forefoot.
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Dors i e xion of the fore foot (Fig. 9.14) For the dorsifexion of the forefoot the proximal left hand can be placed either over the dorsal side of the head and neck of the talus (Fig. 9.14A) or over the plantar surface of the calcaneus (Fig. 9.14B).
• Direction: Dorsifexion of the forefoot. • Symbol: Forefoot DF. • Patient starting position: Prone, 90° knee
produces a counterforce to maintain the position of the hindfoot. If the left hand is placed over the dorsal side of the head and neck of the talus, the counterforce is produced and directed upwards, whereas if the left hand is placed over the plantar surface of the calcaneus the counterforce is produced and directed downwards.
exion. • Therapist starting position: Standing by the patient’s knee, the right knee on the couch to support the patient’s left shin.
Sup ina tion of the fore foot (Fig. 9.15)
Localization of forces (position of therapist’s hands)
exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
• The left hand holds the hindfoot in neutral position. The right hand is placed over the plantar surface of the metatarsals with the thumb over the lateral surface and the ngers over the medial surface of the forefoot.
Application of forces by therapist (method) • Movement is produced with the right hand and arm moving downwards. The left hand and arm
• Direction: Supination of the forefoot. • Symbol: Forefoot Sup. • Patient starting position: Prone, 90° knee
Localization of forces (position of therapist’s hands) • The left hand holds the hindfoot in neutral position. The distal right hand is placed over the dorsal surface of the metatarsals with the thumb over the lateral surface and the ngers over the medial surface of the forefoot.
Application of forces by therapist (method) • The supination movement begins with plantar exion (i.e. sagittal plane movement). The left hand maintains the hindfoot in neutral position and the right hand produces the plantar exion movement. While maintaining the plantar exed position the forefoot is moved into inversion (i.e. frontal plane movement). The last component of the forefoot supination is the
Fig ure 9.14 • Dorsi exion of the forefoot.
Fig ure 9.15 • Supination of the forefoot. 535
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adduction (i.e. transverse plane movement). While doing the transverse plane movement the previous components are maintained.
P rona tion of the fore foot (Fig. 9.16) • Direction: Pronation of the forefoot. • Symbol: Forefoot Pro. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand holds the hindfoot in neutral position. The distal right hand is placed over the plantar surface of the metatarsals with the thumb over the lateral surface and the ngers over the medial surface of the forefoot.
Application of forces by therapist (method) • The pronation movement begins with dorsi exion (i.e. sagittal plane movement). The left hand maintains the hindfoot in neutral position and the right hand produces the
dorsi exion movement. While maintaining the dorsi exed position the forefoot is moved into eversion (i.e. frontal plane movement). The last component of the forefoot pronation movement is the abduction (i.e. transverse plane movement). While doing the transverse plane movements the previous components are maintained. • If passive physiological movements of the hindfoot or forefoot reproduce patient’s symptoms or reveal impaired movements, differentiation testing of the individual joints continues. In the hindfoot differentiation of the distal tibio bular joint, TCJ and STJ is carried out. In the forefoot differentiation begins between transverse joint rows. MTJ, intertarsal joints and tarsometatarsal joints form the three transverse rows in the forefoot.Differentiation of the longitudinal rays, i.e. intermetatarsal spaces, should also be performed.
Pas s ive phys iological rotation and invers ion/evers ion movements o the hind oot In the hindfoot differentiation tests between the joints are carried out with physiological MR/ LR, INV/ EV and accessory movements. Physiological movements of the hindfoot in transverse and frontal planes should be examined independently to screen these movements within different angles of dorsiexion and plantar exion.
Me d ia l rota tion a nd la te ra l rota tion (Fig. 9.17) • Direction: Medial/ lateral rotation of the talus and calcaneus. • Symbols: MR and LR and • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand grasps around the calcaneus Fig ure 9.16 • Pronation of the forefoot. 536
posteriorly with the thumb positioned laterally and the other ngers medially. The right hand
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A
B
Fig ure 9.17 • A Medial rotation and B lateral rotation of the talus and calcaneus.
grasps around the talus anteriorly with the thumb positioned laterally and the index nger medially.
Application of forces by therapist (method) • Both arms rotate simultaneously and equally in the same direction, for example, medial rotation (Fig. 9.17A). This will applymedial rotation to both the STJ and TCJ and test the range, quality and symptom response of the movement. In the case of symptom reproduction, differentiation between STJ and TCJ can be carried out using the rotation–derotation principle. The same test is repeated towards lateral rotation (Fig. 9.17B).
Inve rs ion a nd e ve rs ion (Fig. 9.18) • Direction: Inversion/ eversion. • Symbols: INV/ EV. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand grasps around the calcaneus posteriorly with the thumb positioned laterally and the other ngers medially. The right hand grasps around the talus anteriorly with the thumb positioned laterally and the index nger medially.
Application of forces by therapist (method) • Both arms turn simultaneously and equally in the same direction, for example, inversion (Fig. 9.18A). This will apply inversion to both the STJ and TCJ and test the range, quality and symptom response of the movement. In the case of symptom reproduction, differentiation between the STJ and TCJ can be performed with the same principle as rotation. The same test is repeated towards eversion (Fig. 9.18B).
Pas s ive acces s ory movements o the hind oot Accessory movements of the hindfoot are longitudinal caudad (distraction) and cephalad (compression), transverse movement medially and laterally 537
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and anteroposterior (AP) and posteroanterior (PA) movements. In the examination and differentiation process it is useful to examine the accessory movements with the hindfoot in the position where the physiological movement restrictions occur.
Dis ta l tib io b ula r joint The accessory movements of the distal tibio bular joint are PA, AP and compression. H ypothetically the distal tibio bular joint can also be moved longitudinally. H owever, the movement must be performed with leverage from the hindfoot. The techniques of PA, AP and compression for the distal tibio bular joint are described below.
P os te roa nte rior move me nt (Fig. 9.19) • Direction: Movement of the bula in relation to the tibia in a posteroanterior direction. • Symbols: PA • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The heel or thenar eminence of the left hand is placed against the posterior border of the lateral malleolus with the thumb pointing downwards and other ngers pointing towards the toes.
Fig ure 9.18 • Inversion and eversion. 538
Fig ure 9.19 • Movement of the bula in relation to the tibia in a posteroanterior direction.
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The heel of the right hand is placed against the anterior border of the medial malleolus with the ngers pointing towards the heel.
Application of forces by therapist (method) • The forearms are directed opposite each other and movement is produced with the left arm. The right arm maintains the position of the tibia.
Ante rop os te rior move me nt (Fig. 9.20) • Direction: Movement of the bula in relation to the tibia in an anteroposterior direction. • Symbols: AP • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The heel of the right hand is placed against the anterior surface of the lateral malleolus with the thumb pointing downwards and other
Fig ure 9.20 • Movement of the bula in relation to the tibia in anteroposterior direction.
ngers spreading posteriorly around the ankle. The heel of the left hand is placed against the posterior surface of the medial malleolus with the ngers spreading anteriorly around the ankle.
Application of forces by therapist (method) • The forearms are directed opposite each other and the movement is produced with the right arm. The left arm maintains the position of the tibia.
Comp re s s ion (Fig. 9.21) • Direction: Movement of the bula towards the tibia. • Symbol: • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing at the end of the treatment table, facing along the patient’s leg.
Localization of forces (position of therapist’s hands) • The heel of the left hand is placed on the lateral malleolus and the heel of the right hand
Fig ure 9.21 • Compression: movement of the bula towards the tibia. 539
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on the medial malleolus. The ngers are spread along the line of the lower leg pointing towards the knee.
Application of forces by therapist (method) • The forearms are directed opposite each other and the movement is produced by simultaneous and equal action of both arms along the line of the forearms.
thumb positioned laterally over the lateral malleolus and the other ngers positioned medially over the distal part of the tibia. The left hand is placed behind the talus with the thumb positioned laterally and the index and middle ngers medially, just distal of the malleoli.
Application of forces by therapist (method) • The forearms are directed opposite each other
Ta loc rura l joint The accessory movements of the talocrural joint are PA, AP, distraction and compression. H ypothetically TCJ can also be moved in a transverse direction, but the movement is very small because the distal tibio bular syndesmosis encloses the talus medially and laterally. Therefore, in this text the techniques of PA, AP, compression and distraction are described for TCJ.
P os te roa nte rior move me nt (Fig. 9.22) • Direction: Posteroanterior movement of the talus in relation to the tibia and bula. • Symbols: PA • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The right hand is placed against the anterior surface of the tibia and
bula with the
Fig ure 9.22 • Posteroanterior movement of the talus in relation to the tibia and bula. 540
and the movement is produced with the left arm while the right hand maintains the position of the tibia and bula.
Ante rop os te rior move me nt (Fig. 9.23) • Direction: Anteroposterior movement of the talus in relation to the tibia and bula. • Symbols: AP • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand is placed against the posterior surface of the tibia and bula with the thumb positioned laterally over the lateral malleolus and the other ngers positioned medially over the distal part of the tibia. The right hand is placed in the front of the talus with the thumb positioned laterally and the index and middle ngers medially, just distal of the malleoli.
Fig ure 9.23 • Anteroposterior movement of the talus in relation to the tibia and bula.
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Application of forces by therapist (method) • The forearms are directed opposite each other and the movement is produced with the right arm while the left hand maintains the position of the tibia and bula.
Dis tra c tion (Fig. 9.24) • Direction: Movement of the talus in a caudad direction along the line of the tibia. • Symbols: • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the left knee supporting the posterior aspect of the patient’s left thigh.
Localization of forces (position of therapist’s hands) • The right hand is placed on the front of the talus and the left hand is placed behind the talus. The webs of the rst interosseus space are brought into contact with the talus. The thumbs are positioned laterally and the other ngers medially over the hindfoot.
Application of forces by therapist (method) • The forearms are directed as vertically as possible and both arms equally lift the talus towards the ceiling while the left knee maintains the position of the patient’s thigh.
Comp re s s ion (Fig. 9.25) Compression of the TCJ always includes the compression of the STJ. Therefore, the technique is
Fig ure 9.25 • Compression of the hindfoot.
described as a compression of the hindfoot. H owever, compression may be combined with other movements of the hindfoot.
• Direction: Movement of the hindfoot in a cephalad direction along the line of the tibia. • Symbol: • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee.
Localization of forces (position of therapist’s hands) • The hands are supporting the ankle in neutral position.
Application of forces by therapist (method) • The therapist places the sternum over the patient’s hindfoot. The compression is produced with the weight of the therapist’s upper body.
Movements under compression • Compression of the hindfoot may be combined with physiological or accessory movements. Localization of forces is provided with the same grip that is used for movements without compression and compression is produced with the weight of the therapist’s upper body.
Subtalar joint • In STJ all accessory movements are available.
Fig ure 9.24 • Distraction: movement of the talus in a caudad direction along the line of the tibia.
Compression has already been described above. O ther accessory movements of the STJ are PA, AP, distraction and transverse movements medially and laterally. 541
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Fig ure 9.26 • Posteroanterior movement of the calcaneus in relation to the talus.
Fig ure 9.27 • Anteroposterior movement of the calcaneus in relation to the talus.
P os te roa nte rior move me nt (Fig. 9.26) • Direction: Posteroanterior movement of the calcaneus in relation to the talus. • Symbols: PA • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The right hand is placed against the anterior surface of the talus with the thumb positioned laterally and the other ngers medially. The left hand cups around the posterior surface of the calcaneus with the thumb and ngers spreading over and around the calcaneus.
Application of forces by therapist (method) • The forearms are directed opposite each other and the movement is produced with the left arm while the right hand maintains the position of the talus.
Ante rop os te rior move me nt (Fig. 9.27) • Direction: Anteroposterior movement of the calcaneus in relation to the talus. • Symbols: AP • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin. 542
Fig ure 9.28 • Distraction: Movement of the calcaneus in a caudad direction along the line of the tibia.
Localization of forces (position of therapist’s hands) • The left hand is placed against the posterior surface of the talus with the thumb positioned laterally under the lateral malleolus and the index and middle nger positioned medially under the medial malleolus. The right hand cups around the calcaneus anteriorly and from the plantar side of the heel.
Application of forces by therapist (method) • The forearms are directed opposite each other and the movement is produced with the right arm while the left hand maintains the position of the talus.
Dis tra c tion (Fig. 9.28) • Direction: Movement of the calcaneus in a caudad direction along the line of the tibia.
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• Symbol: • Patient starting position: Prone, 90° knee
Localization of forces (position of therapist’s hands)
exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
• The right hand is placed over the talus and
Localization of forces (position of therapist’s hands) • The right hand is placed in the front of the talus. The rst web space of the left hand is placed on the posterosuperior corner of the calcaneus.
Application of forces by therapist (method) • The left forearm is directed as vertically as possible and the right arm horizontally. The left arm lifts the calcaneus towards the ceiling while the right hand maintains the position of the talus.
Tra ns ve rs e move me nt me d ia lly (Fig. 9.29) • Direction: Transverse movement medially of the
distal tibia medially with the ngers pointing towards the knee. The left hand cups around the calcaneus from the lateral side with the ngers spreading over the calcaneus.
Application of forces by therapist (method) • The forearms are directed opposite each other and the movement is produced with the left arm while the right hand maintains the position of the talus.
Tra ns ve rs e move me nt la te ra lly (Fig. 9.30) • Direction: Transverse movement laterally of the calcaneus in relation to the talus. • Symbols: , • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing at the end of the treatment table, facing along the patient’s leg.
calcaneus in relation to the talus. • Symbols: , • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing at the end of the treatment table, facing along the patient’s leg.
Localization of forces (position of therapist’s hands)
Fig ure 9.29 • Transverse movement medially of the calcaneus in relation to the talus.
Fig ure 9.30 • Transverse movement laterally of the calcaneus in relation to the talus.
• The left hand is placed over the talus and the distal bula laterally with the ngers pointing towards the knee. The right hand cups around the calcaneus from the medial side ngers spreading over the calcaneus.
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Application of forces by therapist (method) • The forearms are directed opposite each other and the movement is produced with the right arm while the left hand maintains the position of the talus.
Pas s ive acces s ory movements o the ore oot If passive physiological movements of the forefoot reproduce the patient’s symptoms or reveal impaired movements further differentiation between joints is established with accessory movements. Differentiation should beginwith the transverse joint rows – the MTJ, intertarsal joints and tarsometatarsal joints form the three transverse rows in the forefoot. Differentiation between longitudinal rays, i.e. intermetatarsal spaces should also be carried out. Two examples of accessory movements between transverse joint rows are described below: AP of the MTJ and transverse movement medially of the MTJ.
Ante rop os te rior move me nt of the MTJ (Fig. 9.31) • Direction: Anteroposterior movement of the navicular and cuboid in relation to the talus and calcaneus. • Symbols: AP • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Fig ure 9.31 • Anteroposterior movement of the MTJ .
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Localization of forces (position of therapist’s hands) • The left hand is placed on the plantar and anterior surface of the calcaneus proximally adjacent to the MTJ. The left hand holds the hindfoot in neutral position.The distal right hand is placed over the dorsal surface of the navicular and cuboid.
Application of forces by therapist (method) • The forearms are directed opposite each other and the movement is produced with the right arm moving upwards while the left hand maintains the position of the calcaneus and the talus.
Tra ns ve rs e move me nt me d ia lly of the MTJ (Fig. 9.32) • Direction: Transverse movement medially of the cuboid and navicular in relation to the calcaneus and the talus. • Symbols: , • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing at the end of the treatment table, facing along the patient’s leg.
Localization of forces (position of therapist’s hands) • The right hand cups the calcaneus and talus medially, with the ngers spreading on the lateral side of the calcaneus. The right hand is
Fig ure 9.32 • Transverse movement medially of the MTJ .
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placed proximally adjacent to the MTJ. The left hand is placed over the cuboideum and navicular from the lateral side of the foot. The index nger is placed over the dorsal side of the cuboideum and navicular distally adjacent to the MTJ. The thumb is over the plantar side of the cuboid and navicular.
Application of forces by therapist (method) • The forearms are directed opposite each other and the movement is produced with the left arm while the right hand maintains the position of the calcaneus and the talus. • If an accessory movement of the transverse joint row reproduces the patient’s symptoms or reveals impaired movement then further differentiation may be performed by repeating the accessory movement with a single joint. An example of this is described below.
Ante rop os te rior move me nt of the me d ia l c une iform (Fig. 9.33) • Direction: Anteroposterior movement of the medial cuneiform in relation to the navicular. • Symbols: AP • Patient starting position: Supine, the heel over the end of treatment table. • Therapist starting position: Standing by the patient’s foot.
Localization of forces (position of therapist’s hands) • The thumb of the right hand is placed over the dorsal side of the navicular and the index and
Fig ure 9.33 • Anteroposterior movement of the medial cuneiform .
middle ngers hold the navicular from the plantar side. The thumb of the left hand is placed over the dorsal side of the medial cuneiform and the index and middle ngers hold the medial cuneiform from the plantar side.
Application of forces by therapist (method) • The left hand moves the medial cuneiform while the right hand maintains the position of the navicular. • Differentiation between intermetatarsal spaces, i.e. rays may be done with accessory movements. For example, AP movement as described below.
Ante rop os te rior move me nt of the IV-ra y (Fig. 9.34) • Direction: Anteroposterior movement of the fourth ray in relation to the third ray. • Symbols: AP • Patient starting position: Supine, the heel over the end of the treatment table. • Therapist starting position: Standing at the end of the treatment table, facing patient’s leg.
Localization of forces (position of therapist’s hands) • The left thumb is placed on the dorsal side of the three medial rays and the index and middle nger are on the plantar side of the same rays. The left hand is perpendicular in relation to the metatarsals. The thumb of the right hand is placed on the dorsal side of the fourth ray parallel with the metatarsal. The index and
Fig ure 9.34 • Anteroposterior movement of the IV-ray.
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middle ngers are on the plantar side of the fourth ray.
Application of forces by therapist (method) • The right hand moves the fourth ray while the left hand maintains the position of the three medial rays.
Combined movement techniques Combined movement techniques may be required in the treatment of movement impairments of the foot and ankle. The use of these techniques is justied when passive movement examination reveals impairments in directions, which can be combined (with other movements) or used in the progression of treatment.
Dors i e xion a nd p os te roa nte rior move me nt of the STJ (Fig. 9.35) • Direction: Combined dorsi exion of the hindfoot and posteroanterior movement of the calcaneus in relation to the talus. • Symbols: H indfoot DF + STJ PA. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The right hand is placed against the anterior surface of the talus with the thumb positioned
Fig ure 9.35 • Dorsi exion and posteroanterior movement of the STJ . 546
laterally and the other ngers medially. The left hand is placed behind the calcaneus with the thumb positioned laterally and other ngers medially around the calcaneus.
Application of forces by therapist (method) • The forearms are directed opposite each other and the posteroanterior movement is produced with the left arm while both arms direct the hindfoot towards dorsi exion simultaneously. Dorsi exion of the hindfoot may be enhanced through exion of the knee.
Dors i e xion a nd a nte rop os te rior move me nt of the TCJ (Fig. 9.36) • Direction: Combined dorsi exion of the hindfoot and anteroposterior movement of the talus in relation to the tibia and bula. • Symbols: H indfoot DF + TCJ AP. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand is placed against the posterior surface of the tibia and bula with the thumb positioned laterally over lateral malleolus and the other ngers positioned medially over the distal part of the tibia. The right hand is placed in the front of the talus with the thumb positioned laterally and the index and middle
Fig ure 9.36 • Dorsi exion and anteroposterior movement of the TCJ .
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ngers medially, just distal of the malleoli. The forefoot is supported underneath the right axilla.
Application of forces by therapist (method) • The forearms are directed opposite each other and the anteroposterior movement is produced with the right arm while the dorsi exion movement is produced through side bending of the therapist’s body to the right.
Dors i e xion a nd c omp re s s ion of the hind foot (Fig. 9.37) • Direction: Combined dorsi exion and compression of the hindfoot. • Symbol: • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee.
Localization of forces (position of therapist’s hands) • The right hand is placed against the anterior
with the weight of the therapist’s upper body while both hands and arms are simultaneously and equally producing the dorsi exion of the hindfoot.
Dors i e xion a nd la te ra l rota tion of the hind foot (Fig. 9.38) • Direction: Combined dorsi exion and lateral rotation of the hindfoot. • Symbols: H indfoot DF + LR. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand grasps around the calcaneus posteriorly with the thumb positioned laterally and the other ngers medially. The right hand grasps around the talus anteriorly with the thumb positioned laterally and the index nger medially.
surface of the talus with the thumb positioned laterally and the other ngers medially. The left hand holds the heel from behind, thumb along the lateral surface and ngers along the medial surface of the heel.
Application of forces by therapist (method) • The therapist places the sternum over the patient’s hindfoot. The compression is produced
Fig ure 9.37 • Dorsi exion and compression of the hindfoot.
Fig ure 9.38 • Dorsi exion and lateral rotation of the hindfoot. 547
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Application of forces by therapist (method) • Both arms rotate equally in lateral rotation while simultaneously producing dorsi exion of the hindfoot.
Dors i e xion a nd a nte rop os te rior move me nt of the ta loc rura l joint a nd d is tra c tion (Fig. 9.39) • Direction: Combined dorsi exion of the hindfoot and anteroposterior movement of the talus in relation to the tibia and bula and distraction of the hindfoot. • Symbols: H indfoot DF + TCJ AP. • Patient starting position: Supine, the heel over the end of the treatment table and with the medial and lateral malleolus supported on the treatment table. • Therapist starting position: Standing by the patient’s foot.
Localization of forces (position of therapist’s hands) • The right hand is placed against the anterior surface of the talus with the thumb positioned laterally and the other ngers medially. The left hand cups the heel from behind and the forefoot is placed against the left forearm.
Application of forces by therapist (method) • The left hand is pulling the heel into the caudal direction along the line of the tibia while the right hand is producing anteroposterior movement of the talus. The left forearm is
Fig ure 9.39 • Dorsi exion and anteroposterior movement of the talocrural joint and distraction. 548
simultaneously leaning against the forefoot and producing the dorsi exion movement.
P la nta r e xion a nd a nte rop os te rior move me nt of the s ub ta la r joint (Fig. 9.40) • Direction: Combined plantar exion of the hindfoot and anteroposterior movement of the calcaneus in relation to the talus. • Symbols: H indfoot PF + STJ AP. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand is placed against the posterior surface of the talus with the thumb positioned laterally under the lateral malleolus and the index and middle nger positioned medially under the medial malleolus. The right hand cups around the calcaneus anteriorly and from the plantar side of the heel.
Application of forces by therapist (method) • The forearms are directed opposite each other and the anteroposterior movement is produced with the right arm while the plantar exion movement is produced through side bending of the therapist’s body to the left.
Fig ure 9.40 • Plantar exion and anteroposterior movement of the subtalar joint.
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P la nta r e xion a nd inve rs ion (Fig. 9.41) • Direction: Inversion. • Symbol: INV. • Patient starting position: Prone, 90° knee exion. • Therapist starting position: Standing by the patient’s knee with the right knee on the couch to support the patient’s left shin.
Localization of forces (position of therapist’s hands) • The left hand grasps around the calcaneus posteriorly with the thumb positioned laterally and the other ngers medially. The right hand grasps around the talus anteriorly with the thumb positioned laterally and the index nger medially.
Application of forces by therapist (method) • Both arms turn simultaneously and equally towards inversion while the plantar exion movement is produced through side bending of the therapist’s body to the left.
Therapeutic exercis es o the oot and ankle Therapeutic exercises of the foot and ankle are a cornerstone of the movement intervention in musculoskeletal foot and ankle disorders. Exercises are required to restore the patient’s active movement capacity and performance. Therapeutic exercises may be the primary intervention for the foot and ankle disorder or they may follow the passive manual treatment to normalize the motor control of the foot and ankle. The physiotherapist should consider all factors contributing to the patient’s foot and ankle disorder when exercises are planned and implemented. For example, a patient with hindfoot dorsi exion movement impairment may need exercises to mobilize ankle joints to maintain mobility after passive mobilization, stretch calf muscles, mobilize neural tissue, regain the normal relaxed movement pattern and get rid of the withdrawal activity or to regain trust of movement through graded exposure into the dorsi exion. The selection of exercises is based on identifying the direction of the impairment. In the following
Fig ure 9.41 • Plantar exion and inversion.
descriptions exercises are explained based on the functioning of the foot and ankle.
Mobility exercis es Mob iliza tion of the a nkle into d ors i e xion (Fig. 9.42) • Direction: Dorsi exion. • Patient starting position: Standing with the left foot on the oor and the right foot on a chair. The right foot is in neutral position and the lower leg is vertical or mildly leaning backwards. The upper body is leaning against the right thigh. (Fig. 9.42A) • With the right hand, the patient grasps around the toes to dorsi ex the toes and plantar ex the rays, i.e. to lift the arches of the foot. This will lock the movement of the MTJ and forefoot and direct the movement to the ankle. The best way to accomplish a proper position is to support the toes against the base of the palm and place the ngers underneath the heads of the metatarsals. With the left hand the patient may support the hindfoot directly downwards to hold the heel on the chair. With the left hand the patient can monitor the position of the hindfoot. (Fig. 9.42B) • Aim o the exercise: To mobilize the ankle towards dorsi exion. The desired effect of the mobilization is dependent on the factors limiting the physiological range of movement. The limiting factors may be physical (i.e. tightness of the tissues or overactive 549
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Mobilization o the ankle into dors i exion
A
B
C
D
Fig ure 9.42 • A Starting position. B With the right hand, the patient grasps around the toes to dorsi ex the toes and plantar ex the rays, i.e. to lift the arches of the foot. C The position of the foot is maintained throughout the movement with the hands. The only part moving is the right lower leg. D Lower leg leans forwards and this is accomplished by transferring the centre of gravity. Transference is controlled with the activity of the left lower extremity and with the movement of the body leaning against the right thigh.
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Mob iliza tion of the a nkle in d iffe re nt d ire c tions with a b a la nc e b oa rd (Fig. 9.43) • Direction: Any direction of the foot and ankle
Fig ure 9.43 • Mobilization of the ankle in different directions with balance board.
withdrawal re ex creating compression and stiffness of the ankle joints) or psychological (i.e. fear of movement-related pain). Depending on the mechanism leading to impairment the patient’s focus during movement may vary a lot. Some patients may have to feel a stretch of tissues whereas others may have to concentrate on keeping the ankle relaxed during movement. • Per orming the exercise: The right foot on the chair is mobilized. The position of the foot is maintained throughout the movement with the hands. The only part moving is the right lower leg. The lower leg leans forward and this is accomplished by transferring the centre of gravity. Transference is controlled with the activity of the left lower extremity and with the movement of the body leaning against the right thigh. It is crucial that the right ankle is relaxed during the mobilization. Through relaxed movement the full potential of the physiological range of movement in dorsi exion is accomplished. Movement is done in rhythm without a pause between the available range of dorsi exion and the starting position. Usually the movement is repeated 15–20 times (Figs. 9.42C and 9.42D).
or combination of movements. • Patient starting position: Sitting with the right foot on the balance board. The foot is positioned in the middle of the balance board. • Aim o the exercise: This exercise is mainly used for patients with movement impairments where pain-related fear of movement contributes to the foot and ankle pain and disability. The aim of this exercise is to gradually expose the foot and ankle into the impaired movement direction, regain trust of movement in the impaired direction and restore normal physiological range of movement. • Per orming the exercise: The patient is encouraged to move gradually into the direction of impairment. The rim of the board is used to limit the movement. The patient is made aware that the movement cannot go beyond the normal physiological range of movement. Forefoot activation may be used to encourage the independent movement control between forefoot and hindfoot. Forefoot activation will increase the sense of control and allow the hindfoot to move more freely.
Motor control: exercis es in a s itting pos ition Usually motor control exercise intervention is initiated in a sitting position where most patients can start to activate the foot and ankle without the need to avoid pain. Therefore, ideal coordination of movement can be achieved from the very beginning of the exercise intervention. Patients can also regain an awareness of motor control of the different regions of the foot and ankle before progressing into the weight-bearing situation.
Ac tiva tion of the fore foot (Fig. 9.44) • The rst activation strategy is described in detail and variations are shown in photographs. • Patient starting position: Sitting with the foot on the ground. The lower leg is vertical and the foot is in a relaxed position (Fig. 9.44A). 551
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• Aim o the exercise: To activate the heads of
• In the second phase of the exercise the active
the rst and fth metatarsals against the ground. • Per orming the exercise: In the rst phase the patient dorsi exes the big toe ( rst MTP) approximately 20°. After this the rst ray should start to plantar ex resulting in a reinforced support on the ground under the head of the rst metatarsal. The patient continues to dorsi ex the big toe and maintains the contact under the heads of the rst and fth metatarsals. The vertical alignment of the lower leg is maintained. Dorsi exion of the big toe continues until the longitudinal arches of the foot are raised. Because the active forefoot contact is maintained the foot shortens (Fig. 9.44B).
support of the rst and fth metatarsals is maintained against the ground while the big toe is brought down and all toes are relaxed (Fig. 9.44C). After the relaxation of the toes the longitudinal arches should be raised, the foot shortened and the pretibial muscles relaxed. • In the third phase of the exercise the forefoot is relaxed and that will result in lowering of the arches and lengthening of the foot, i.e. returning to the starting position of the exercise (Fig. 9.44D). • Brie y, the phases of this exercise are: activation of the forefoot, maintaining the activation while relaxing the toes and relaxing the forefoot.
Activation o the ore oot
A
B
C
D
Fig ure 9.44 • A Starting position of the patient. B The patient continues to dorsi ex the big toe and maintains the contact under the heads of the rst and fth metatarsals until the longitudinal arches of the foot are raised; because the active forefoot contact is maintained the foot shortens. C The active support of the rst and fth metatarsals is maintained against the ground while the big toe is brought down and all toes are relaxed. D The forefoot is relaxed that will result in lowering of the arches and lengthening of the foot, i.e. returning to the starting position of the exercise.
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Activation o the ore oot—cont’d
E
F
G
Fig ure 9.44A • c o nt’d E The same exercise and phases may be carried out through dorsi exion of the second to fth toes. F Alternatively, the same exercise and phases may be carried out through dorsi exion of all toes. G At advanced level the patient may be able to activate the heads of the rst and fth metatarsals directly against the ground without dorsi exion of the toes.
• The same exercise and phases may be carried out through dorsi exion of the second to fth toes (Fig. 9.44E) or with all toes (Fig. 9.44F). At advanced level the patient may be able to activate the heads of the rst and fth metatarsals directly against the ground without dorsi exion of the toes (Fig. 9.44G ).
been restricted or the counter-rotation between forefoot and hindfoot has been impaired in this direction. • Per orming the exercise: The forefoot is activated through dorsi exion of the second to fth toes.
Dis s oc ia tive hind foot s up ina tion (Fig. 9.45) • Patient starting position: Sitting with the foot on the ground. The lower leg is vertical and the foot is in a relaxed position. • Aim o the exercise: To restore and reinforce the independent movement control between the hindfoot and the forefoot. This exercise can be used when the medial loading of the hindfoot is increased, lateral loading of the hindfoot has
Fig ure 9.45 • Dissociative hindfoot supination. 553
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Active support of the rst and fth metatarsals is maintained against the ground. The hindfoot is moved towards supination. Under the heel weight is transferred onto the outer part of the heel pad. Simultaneously, in the forefoot the active support under the rst metatarsal should increase. This will result in lifting and shortening of the medial longitudinal arch.
Dis s oc ia tive hind foot p rona tion (Fig. 9.46) • Patient starting position: Sitting with the foot on the ground. The lower leg is vertical and the foot is in a relaxed position. • Aim o the exercise: To restore and reinforce the independent movement control between the hindfoot and forefoot. This exercise can be used when the lateral loading of the hindfoot is increased, the medial loading of the hindfoot has been restricted or the counter-rotation between the forefoot and the hindfoot has been impaired in this direction. • Per orming the exercise: The forefoot is activated through dorsi exion of the rst toe. Active support of the rst and fth metatarsals is maintained against the ground. The hindfoot is moved towards pronation. Under the heel weight is transferred onto the inner part of the heel pad. Simultaneously, in the forefoot the active support under the rst and fth metatarsals should increase. It is crucial that the active support under the fth metarsal in maintained. This will result in lifting and shortening of the lateral longitudinal arch.
Fig ure 9.46 • Dissociative hindfoot pronation. 554
Inte gra tive hind foot p la nta r e xion (Fig. 9.47) • Patient starting position: Sitting, with the foot on the ground. The lower leg is vertical and the foot is in a relaxed position. • Aim o the exercise: To integrate the heel lift in the active and independent support of the forefoot. This will reinforce the independent movement control between the forefoot and hindfoot. • Per orming the exercise: The forefoot is activated and the active support of the rst and fth metatarsals is maintained against the ground. The movement is performed by lifting the heel towards the ceiling and activating the forefoot on the ground. An equal amount of force is produced in both directions. At the beginning, the movement is performed within the range in which the forefoot activity against the ground can be maintained. It is important to direct the movements vertically, in the forefoot towards the ground and in the hindfoot towards the ceiling. Within the middle range of this movement the fth metatarsal is detached from the ground. After this the control of movement is maintained through active support of the rst metatarsal. The most challenging part of this exercise is to start the return and maintain the forefoot activity on the ground
Fig ure 9.47 • Integrative hindfoot plantar exion.
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Fig ure 9.48 • Squat (emphasis on foot and ankle control).
when the movement direction of the ankle changes towards dorsi exion. The active forefoot control is maintained until the heel is on the ground. During the ankle movement toes and pretibial muscles should be relaxed.
Motor control: exercis es in a s tanding pos ition All exercises that are described in a sitting position can be repeated in a standing position. Exercises in standing are a progression from exercises in a sitting position. The patient can then progress further to exercises in single-leg standing. In the standing position it is crucial for the patient to identify the difference between forefoot loading and active forefoot support against the ground. Active support of the forefoot is a prerequisite for the foot and ankle to maintain the arches of the foot, direct the loading to bony structures designed for weight bearing, provide a stable base for ankle movements and to enable counter-rotation between the forefoot and hindfoot. An important exercise in the standing position is squatting. Impaired dorsi exion of the ankle is probably the most typical nding in foot and ankle disorders.
Sq ua tting (e mp ha s is on foot a nd a nkle c ontrol) (Fig. 9.48) • Patient starting position: Standing in relaxed position with the feet approximately a shoulderwidth apart. • Aim o the exercise: To promote active forefoot control during squatting and achieve full range of ankle movement into dorsi exion. • Per orming the exercise: The forefeet are activated and the active support of the rst and fth metatarsals is maintained against the ground (Fig. 9.48A). Forefoot activity is necessary to achieve independent movement control between the forefoot and the hindfoot and to achieve full dorsi exion of the ankle. The patient squats and controls the movement of the lower legs with the calf muscles. The patient is directed to allow free ankle movement. Activity of the pretibial muscles is avoided during ankle movement (Fig. 9.48B). Simultaneous activity of the calf and pretibial muscles would create compression and stiffness into the ankle joints. At the beginning the movement is performed within the range at which the patient can maintain forefoot control. G radually movement is progressed into the full range of ankle dorsi exion.
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El-Metwally A, Salminen JJ, Auvinen A, et al: Risk factors for traumatic and non-traumatic lower limb pain among preadolescents: a populationbased study of Finnish schoolchildren, BM C M usculoskelet Disord 7:3, 2006. doi:10.1186/ 1471-2474-7-3. Elveru RA, Rothstein JM, Lamb RL, et al: Methods for taking subtalar joint measurements – a clinical report, Phys Ther 68(5):678–682, 1988. Elvey RL, O ’Sullivan PB: A contemporary approach to manual therapy. In: Boyling JD, Jull GA, editors: G rieve’s M odern M anual Therapy – The Vertebral C olumn, Edinburgh, 2004, Elsevier Churchill Livingstone, pp 471–493. G aida JE, Alfredson H , Kiss ZS, et al: Asymptomatic Achilles tendon pathology is associated with a central fat distribution in men and a peripheral fat distribution in women: a cross sectional study of 298 individuals, BM C M usculoskelet Disord 11:41, 2010. http:/ / www.biomedcentral.com/ 14712474/ 11/ 41 (accessed 30 April 2013). H amill J, H olt KG , Derrick TR: Biomechanics of the foot and ankle. In: Sammarco G J, editor: Rehabilitation o the Foot and Ankle, St Louis, 1995, Mosby, pp 25–44. H ermans JJ, Beumer A, de Jong TAW, et al: Anatomy of the distal tibio bularsyndesmosis in adults: a pictorial essay with a multimodality approach, J Anat 217:633–645, 2010. H errmann TJ: The foot and ankle in football. In: Sammarco G J, editor: Rehabilitation o the Foot and Ankle, St Louis, 1995, Mosby, pp 259–268. H ill CL, G ill TK, Menz H B, et al: Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study, Journal o Foot and Ankle Research 1:2, 2008. Doi: 10.1186/ 1757-1146-1-2. H ubbard TJ, Kramer LC, Denegar CR, et al: Correlations among multiple measures of functional and mechanical instability in subjects with chronic ankle instability, J Athl Train 42(3):361–366, 2007. H ubbard TJ, H icks-Little CA: Ankle ligament healing after an acute ankle sprain: an evidence-based approach, J Athl Train 43(5):523–529, 2008.
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The Maitland Conc e pt as a c linic al prac tic e frame work fo r ne uro mus c ulo s ke le tal dis o rde rs
1. The culture within which the Maitland Concept operates is to encourage clinicians to: a] Improve adopt adapt b] Adapt adopt improve c ] Adopt improve adapt d] None of the above 2. Which of these are included as the main pillars of manipulative physiotherapy clinical practice? a] Clinical reasoning b] Patient centred practice c ] Assessment examination and treatment d] All of the above 3. Complete this title. The International Classi cation of Functioning, Disability and …: a] Disease b] Impairment c ] H ealth d] H andicap 4. H ealthy life expectancy means: a] Adding life to years b] Adding years to life c ] a and b d] Living to 100 years old 5. According to the IFO MPT, competency should include: a] Knowledge b] Skill
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c ] Attributes d] a, b and c 6. In the domain of outcome measures, PRO MS stands for: a] Patient reported outcome measures b] Patient related objective markers c ] Problems with range of movement d] Passive range of muscle spasm 7. Which of the following is not a feature of the patient’s body’s capacity to inform? a] The effects of treatment on symptoms and signs b] The therapist’s skills in manual therapy c ] The patient’s responses to painful movement d] The patient’s overall satisfaction with the outcome of treatment 8. Collaborative reasoning is not: a] Therapist centred b] Patient centred c ] Semi-structured interviewing d] Planning physical examination with the patient 9. Metacognition is best described as: a] Thinking about what you are thinking b] Evidence based practice c ] The treatment technique d] Reasoning in action e1
The Maitland Co nc e pt as a c linic al prac tic e frame wo rk
10. Which of these features belongs to the clinical side of the brick wall model of clinical reasoning? a] Painful knee extension b] Nociception c ] In ammatory soup d] Femoral roll spin and slide 11. Manual examination should not be designed around: a] The source of the patient’s symptoms b] X-ray changes c ] Contributing factors d] Movement impairments 12. The movement continuum theory of physiotherapy practice demands that Physiotherapists think about movement in relation to a] Tissues b] Cells c ] The person in society d] All of the above 13. Which of the following is not an asterisk? a] Volume of medication b] Severity of pain with daily activity c ] The number of past episodes d] Active range of movement 14. Planning of physical examination should be carried out: a] Before the subjective examination b] After reading the referral letter c ] After completion of the subjective d] After observing the patient’s movements 15. Reassessment of each treatment technique is best carried out: a] During the treatment b] After the treatment c ] Before during and after the technique is performed d] At the start of the next session only
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16. Which of the following features may act to inhibit responses to manipulative physiotherapy? a] Symptoms of a mechanical behaviour b] Previous good response to manipulative physiotherapy treatment c ] Signs of impairment related to movement d] Maladaptive thoughts and behaviours 17. Which of the following is not one of the IFO MPT educational standards dimensions a] Knowledge of alternative medicines b] Advanced levels of clinical reasoning skills c ] Comprehensive knowledge of behavioural sciences d] Appreciation of the process of research 18. Autonomous practice is characterised by which two of the following? a] Working under the supervision of orthopaedic practitioners or consultants b] Independent self-determined professional judgement and action c ] Carrying out treatments under prescription from the referring doctor d] Exercising pro essional judgement within a clearly def ned scope o practice 19. Movement diagrams were developed solely as: a] O utcome measures b] A measure of movement impairment c ] A teaching and communication aid d] A legal requirement for documentation 20. Which of the following statements is most appropriate description of the paradigm within which manipulative physiotherapists operate? a] The biopsychosocial model of health care is the only model physiotherapists should use b] Physiotherapists think about the biomedical model primarily c ] Both the biomedical and biopsychosocial models are important to physiotherapists d] The use of the biomedical model is much more important for physiotherapists
The Maitland Conc e pt: e vide nc e -bas e d prac tic e and mo ve me nt s c ie nc e s
O ne or more of the answers maybe correct. 1. The science of physiotherapy is established in: a] Biomedical sciences b] Biomechanical science c ] Movement science d] Rehabilitation science 2. Cott et al.’s movement continuum theory (1995): a] Builds up upon H islop’s cybernetic model of movement (1975) b] Focuses on movement capacity and potential of different levels of movement c ] These levels of movement are not interrelated d] These levels of movement are only in uenced by internal factors 3. The International Classi cation of Functioning, Disability and H ealth (ICF) and physiotherapy diagnosis: a] Are not related b] Physiotherapy diagnosis is expressed in terms of movement functions and dysfunctions c ] The categories of impairments, activities and participation of the ICF are very suitable to express physiotherapy diagnosis d] Particularly manipulative physiotherapy has developed its strength in the diagnosis and
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treatment of movement disorders at impairment levels of ICF 4. The application of evidence-based practice: a] And clinical reasoning are strongly related b] Is related to making decisions for patients based on the best available evidence c ] O nly randomised clinical trials and reviews/ meta-analyses should be considered as best evidence d] Q ualitative research and evidence based practice are not related 5. The practice guidelines: a] Need to be applied as in the guideline, otherwise the clinician may be held liable b] May serve as an essential aid in clinical decision making, but the clinician needs to assess if the guidelines are fully applicable to the individual case c ] Carry an inherent risk that decisions about norms and values are shifted from the clinician’s consultation room to the conference room of the professional association d] If a patient’s problem may be related to different practice guidelines, the clinician selects the most suitable one as a guideline for decisions e3
The Maitland Co nc e pt: e vide nc e -bas e d prac tic e and mo ve me nt s c ie nc e s
6. In paradigms to movement: a] Physiotherapist employs various paradigms to movement simultaneously b] O nly biomechanics are relevant to physiotherapy science and practice c ] O nly neurophysiology is relevant to physiotherapy science and practice d] O nly those paradigms from those areas where lots of research is done, need to be employed 7. Physiotherapy diagnosis a] Is expressed in terms of functions, disability and health b] Is directly related to biomedical, structural diagnosis c ] Is based on subjective and physical examination procedures d] Is based on treatment procedures and subsequent reassessment procedures 8. The biomedical paradigms in physiotherapy practice: a] Establish precautions, contraindication to treatment b] Are an outdated paradigm c ] Serve in medical and/ or orthopaedic diagnosis d] Are a part of clinical patterns recognition for physiotherapist, as long as these patterns are linked to decisions regarding examination and/ or treatment 9. Biopsychosocial paradigms in physiotherapy: a] Enhance a client-centred attitude b] Encompass salutogenic perspectives to practice c ] Focus on the individual illness experience and behaviour d] Should not neglect the ‘bio’ parts of a problem, since the psychosocial aspects has received so much more attention in the past decade 10. Salutogenesis as a contrast to pathogenesis has been developed as a concept by Antonowsky (1979). Which of the following statements is correct? a] Physiotherapists often intrinsically employ an salutogenic attitude in daily practice b] Sense of coherence is an essential aspect of the salutogenic concept e4
c ] H ealth is just the other side of the coin of being ill d] In a salutogenic approach to treatment no special attention needs to be given to communication and the selection of words 11. Neurophysiological models in physiotherapy practice: a] Serve to develop a broader understanding of the pain experience b] Should not be used in educational sessions with patients, as it will only lead to confusion c ] O nly nociceptive and peripheral neurogenic pain mechanisms are of relevance. d] Central nervous system mechanism belong in the care of psychologist 12. Cognitive behavioural approaches to practice: a] De ne the different roles a clinician may take during treatment to enhance change in a patient b] Should consider the various phases of change through which individuals may go before a change in behaviour is established c ] Compliance enhancement is an important aspect of a cognitive behavioural approach d] Can be employed during any phase of examination and treatment 13. Theoretical biomechanical models as, for example, theories on coupling movements of the spine or convex–concave rule of movements of peripheral joints: a] Are contradictory, therefor they should not be employed in clinical practice b] Serve as the only means to make decisions regarding treatment with passive movement c ] The models need to be considered in the context of pathological changes and structural differences and may enhance initial decision making with regards to the selection of treatment d] The models need to be linked to clinical information as for example changes in perceived resistance and pain. They have to be monitored by reassessment procedures.
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Manag e me nt o f c raniomandibular dis orde rs
1. Intra-articular ligaments of the temporomandibular joint are: A. Lig. temporomandibulare laterale B. Lig. disco-temporale C. Lig. disco-condylare D. Lig. spheno-mandibulare a] A and B are correct b] B and C are correct c ] A and D are correct d] all are correct 2. As masticatory (chewing) muscles are considered: A. M. masseter, pars profundus and pars super cialis B. M. temporalis, pars anterior and pars posterior C. M. pterygoideus medialis, pars anterior and pars posterior D. M. pterygoideus lateralis, pars inferior, pars intermedius and pars superior a] All are correct b] O nly A and B are correct c ] O nly A and C are correct d] O nly A, C and D are correct 3. The anterior temporomandibular joint capsule shows attachments with: A. Discus articularis B. O s temporale, anterior of the tuberculum or eminentia articulare C. Condylus mandibulare D. M. pterygoideus lateralis, pars superior
a] b] c] d]
All are correct O nly A and C are correct O nly B, C and D are correct O nly A and B are correct
4. Typical physiological characteristics of the discus articularis of the temporomandibular joint are: A. Three-dimensional biconcave hat shaped B. The posterior border is in the vertical line on top of the head of the mandible or slightly anterior (11 or 12 o’clock position) and shows two ligamentous attachments C. Designed for equilibration and suspension between the fossa of the temporal bone and mandibular head in all positions of the mandible D. Can move over the mandibular head passively; muscular activity is not required a] O nly A and C are correct b] O nly B and D are correct c ] O nly A, B and C are correct d] All are correct 5. Excursive movements of the temporomandibular joint are: A. Depression B. Elevation C. Protraction D. Lateral movements a] All are correct b] O nly A and B are correct c ] O nly A, C and D are correct d] O nly B and D are correct e5
Manag e me nt o f c ranio mandibular dis o rde rs
6. Physiological characteristics of depression (mouth opening) are: A. Average range of motion measured between the incisives is 36–50 mm, including overbite B. Average range of motion measured between the incisives is equal with the width of two ngers of the same person C. Condylar rotation along a frontal axis during initial depression (arthrokinematics of the lower joint compartment) D. Limited mouth opening is related with the occurrence of mental depression a] O nly A and C are correct b] O nly B and D are correct c ] O nly A, B and D are correct d] All are correct 7. The temporomandibular joint differs from most other synovial peripheral joints in the human body by: A. The temporomandibular joint never develops degenerative changes B. The head of the mandible has brous cartilage C. The left and right joints have one common distal joint partner D. Teeth contribute to movement behaviour, movement guidance and resting position of the joint a] All are correct b] O nly B and C are correct c ] O nly B and D are correct d] O nly B, C and D are correct 8. Functions of the various fascicles of the lateral pterygoid muscle are: A. Stabilizing the disc-condyle complex B. Eccentric activity on incursive movements such as mouth closing C. Concentric activity on lateral movement D. Swallowing a] All are correct b] O nly A and C are correct c ] O nly B and D are correct d] O nly A, B and C are correct 9. Stomatognathic muscles regularly showing tender or trigger points are: A. M. pterygoideus medialis, M. masseter and M. temporalis e6
B. M. digastricus C. M. buccinator D. M. orbicularis oris, Mm. levator and depressor anguli ori a] All are correct b] O nly A and B are correct c ] O nly B and D are correct d] O nly A and C are correct 10. Which suprahyoidal muscle receives its motor innervation from the cervical spine? a] M. digastricus, venter posterior b] M. mylohyoideus c ] M. geniohyoideus d] M. stylohyoideus 11. Which infrahyoidal muscle receive motor innervation from the cervical spine? A. M. sternohyoideus B. M. thyrohyoideus C. M. sternothyroideus D. M. omohyoideus a] All are correct b] O nly A and C are correct c ] O nly B and D are correct d] O nly A, B and C are correct 12. Main aims of myofunctional therapy are: A. lip closing B. gain control over tongue movements and position e.g. at swallowing C. support orthodontic management D. having fun at children’s birthdays a] All are correct b] O nly A and C are correct c ] O nly B and D are correct d] O nly A, B and C are correct 13. Peripheral somatic nerves that contribute to the sensory innervation of the head are: A. N. trigeminus including its main branches N. opthalmicus, N. maxillaris and N. mandibularis B. N. facialis C. N. accessorius and N. hypoglossus D. N. spinales C1–3 a] O nly A and C are correct b] O nly B and D are correct c ] O nly A, B and D are correct d] All are correct
M a n a g e m e n t o f c ra n io m a n d ib u la r d is o rd e rs
14. The caudad part of the spinal nuclei of the trigeminal nerve (Nucleus trigemino-cervicalis, pars caudalis)… A. Receives sensory input of the mandibular, temporal and frontal region of the head B. Stretches out caudally to at least the myelum segment C3 C. Shares the dorsal horns with incoming afferents from the upper cervical segments D. Differs in its organizational pattern from the three main peripheral end branches of the N. trigeminus that innervate the skull a] O nly A and C are correct b] O nly B and D are correct c ] O nly A, B and D are correct d] All are correct 15. Functions of the emotional motor system (EMS), descending efferent loops from the limbic system to motor nuclei, are considered: A. Vocalization B. Licking, chewing and swallowing C. Mimic expression D. Lordosis behaviour, including hormonal components a] O nly A and C are correct b] O nly B and D are correct c ] O nly A, B and D are correct d] All are correct 16. Antero-posterior accessory movement of the mandible is considered to: A. Load the retrodiscal bilaminar zone and the posterior joint capsule of the temporomandibular joint B. Indicate an intra-articular dysfunction if painful or de nitely limited C. Being one component of the retruding grinding movement (in bruxism) D. Promote non-physiological posterior translation in the lower compartment a] All are correct b] O nly A and C are correct c ] O nly B and D are correct d] O nly A, B and C are correct
A. B. C. D.
longitudinal cephalad longitudinal caudad transverse medially anteroposterior a] All are correct b] O nly A and D are correct c ] O nly B and C are correct d] O nly A, B and D are correct
18. O verlapping characteristics of the upper cervical spine and the stomatognathic tract include: A. Both can show similar areas of pain and complaints B. Both may be the source of facial pain at daily activities such as eating C. Arthrokinematic interrelationship: upper cervical movements affect mandibular resting position and mandibular movements may demand cervical movement or stability D. Nociceptive input from trigeminal and upper cervical innervated areas share common dorsal horns of the myelum a] O nly A and C are correct b] O nly B and D are correct c ] O nly A, B and D are correct d] All are correct 19. The role of the physical therapist in the overall management of craniomandibular dysfunction may include: A. Providing passive movement techniques, e.g. for the mandible and hyoid bone B. Instructing active training of masticatory, hyoidal, cervical and or mimic muscles C. Providing other interventions such as myofeedback, electromassage, taping (elastic), trigger point treatment, relaxation D. Contributing to clinical diagnosis and formulation of the management plan a] O nly A and C are correct b] O nly B and D are correct c ] O nly A, B and D are correct d] All are correct
17. Accessory movements that can be considered useful contributing treatment directions in intra- or peri-articular temporomandibular joint disorders are: e7
Manag e me nt o f c ranio mandibular dis o rde rs
20. Apart from physical therapy modalities, the overall management of cranio-mandibular dysfunction may include: A. splint therapy B. anti-in ammatory medication C. orthodontic management with braces and or occlusal correction (abrading) / teeth restoration D. change of anti-concepive medication a] O nly A and C are correct b] O nly B and D are correct c ] O nly A, B and D are correct d] All are correct
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Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis orde rs
O ne or more o the answers maybe correct. 1. What benef ts does the extended scope physiotherapist role bring to the physiotherapy pro ession? a] Increased breadth o medical knowledge b] Increased prof le o physiotherapy c ] Extended clinical career ladder d] All o the above 2. Which o the below options best demonstrates how a physiotherapy diagnosis differs rom a medical diagnosis? a] A physiotherapy diagnosis relates to both the management and prognosis o an individual. b] Physiotherapy diagnosis is concerned with classi ying the consequences o a patient’s disease, injury or disorder c ] Physiotherapy diagnosis is concerned with the determination o the cause o a patient’s illness or su ering d] All o the above 3. As a physiotherapist what are the limitations one should be aware o when considering the medical diagnostic titles associated with shoulder conditions? Tick all which apply. a] There is a lack o uni ormity in the way shoulder conditions are labelled b] The manner in which diagnostic labels are def ned is inconsistent
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c ] A variety o shoulder classif cation systems have been shown to have poor inter-rater reliability d] There are di f culties associated with establishing links between pathology and symptomology 4. Which o these orthopaedic special tests are considered to be diagnostically discriminatory? a] External rotation lag sign b] H awkins-Kennedy test c ] Biceps load II test d] None o the above 5. Which issues have been reported in the literature which may help to explain the disappointing diagnostic accuracy and reliability o the shoulder orthopaedic special tests? Tick all which apply. a] Pain inhibition b] Anatomical validity c ] Inconsistent operational def nitions d] Widespread research methodological shortcomings 6. Physiotherapy treatment should primarily be based upon which o the ollowing? a] The re erring practitioner’s diagnosis b] The patient’s unctional impairments c ] The results o any medical investigations d] The theoretical impression o the disorder e9
Manag e me nt o f s ho ulde r and s ho ulde r g irdle dis o rde rs
7. With regards to imaging and rotator cu pathology, which o the ollowing statements is true? a] O n balance both ultrasound and MRI are accurate in the detection o ull thickness rotator cu tears b] O n balance both ultrasound and MRI are accurate in the detection o partial thickness rotator cu tears c ] There is a high correlation between increasing age and rotator cu tears d] The detection o a rotator cu tear signif es the cause o the patient’s shoulder pain or unctional loss 8. Which o the ollowing have been proposed as theoretical aetiological mechanisms or rotator cu tendinopathy/ subacromial impingement? a] Movement disorders o the scapula b] Excessive superior humeral head migration c ] Intrinsic tendon mechanical overload d] All o the above 9. Which o the ollowing should be considered as red ags during the shoulder examination? a] Previous history o cancer b] Progressive well localised pain, o ten night predominant c ] Unexplained wasting, signif cant sensory or motor def cit d] Local shoulder redness and systemically unwell 10. Which o the ollowing situations should be considered to require early medical intervention? a] A young adult with acute traumatic primary anterior shoulder dislocation b] Severe, irritable movement related shoulder pain c ] Recent trauma with acute disabling pain and signif cant weakness d] A young adult with symptoms suggestive o atraumatic instability who shows no response to three sessions o treatment 11. When examining the shoulder the screening process o the cervical spine should include: a] Active cervical movements b] Cervical quadrants and compression tests c ] Cervical passive accessory intervertebral movements e 10
d] Meticulous reassessment o the subjective and physical asterisks post cervical examination 12. From the ollowing list o nerves identi y the one which is not capable o producing pain in the deltoid region o the upper arm. a] The suprascapular nerve b] The axillary nerve c ] The long thoracic nerve d] C5 nerve root 13. Which o the ollowing impairments have been associated with the medical diagnostic term o subacromial impingement? a] Minor glenohumeral instability b] G lenohumeral joint sti ness c ] Sterno-clavicular joint sti ness d] Scapular dyskinesis 14. Which o the below patients is most likely to have sustained a ull thickness rotator cu tear? a] A sedentary male o 30 years with severe shoulder pain o an insidious onset b] A 21-year-old pro essional tennis player with severe shoulder pain whilst serving c ] A 65-year-old gentleman with severe shoulder pain ollowing a FO O SH d] A 40-year-old gentleman with severe shoulder pain ollowing a li ting incident 15. A 40-year-old lady with type II diabetes presents with a 6 week history o an insidious onset o severe shoulder pain disturbing her sleep. Which o the ollowing medical diagnostic terms would you consider to be most likely? a] G lenohumeral osteoarthritis b] Calcif c tendonitis c ] Frozen shoulder d] Subacromial impingement 16. A 70-year-old lady presents with a medical diagnosis o glenohumeral OA. You have established that her main disability is a di f culty astening her bra behind her back. Which one o these physical impairments is most likely to be relevant? a] Reduced upward elevation and outward rotation o the scapula b] A weakness in resisted lateral rotation c ] Reduced thoracic extension d] Sti glenohumeral joint medial rotation
M a n a g e m e n t o f s h o u ld e r a n d s h o u ld e r g ird le d is o rd e rs
17. A weight li ter presents with an inability to per orm a bench press. You have identif ed that the movement impairment is a pain ul restriction to horizontal extension in 90° abduction. Which components need to be assessed to determine the cause o this movement impairment? a] The intra-articular and peri-articular glenohumeral joint structures b] The upper limb neural provocation test 1 c ] The f rst and second ribs d] The cervical spine 18. A patient is re erred to Physiotherapy post subacromial decompression with a pain ul restriction to orward elevation. Which o the points below should be considered in the patient’s management? a] A knowledge o the healing times and surgical intervention undertaken b] The surgeon’s post-operative protocol c ] The patient’s unctional loss and aims or treatment d] Identif cation o all possible components contributing to movement impairments
19. Which o the ollowing statements and requirements are considered as essential to the Maitland concept? a] An open-minded attitude to treatment techniques, being able to innovate reely, unhindered by theory and to relate the techniques to unctional disturbances. b] Flawless analytical assessment. Validationproving each step in the clinical situation. c ] Not allowing theoretical knowledge, or the lack o it to obstruct seeing or f nding clinical acts. d] Making use o the patient’s unctional movements, with which he/ she can demonstrate his/ her disability or disorder. 20. What clinical in ormation can be gleaned rom a positive H awkins–Kennedy test? a] Internal rotation o the arm in 90° scapular elevation is pain ul b] Subacromial impingement is present c ] The underlying pathology is a supraspinatus tendinopathy d] Subacromial bursitis is the likely cause o symptoms
e 11
Manag e me nt o f e lbo w dis o rde rs
1. The articular surfaces of the humeroulnar joint and the type of joint formed are best described as: a] Concave/ convex and biaxial b] Saddle-shaped and uniaxial c ] Saddle shaped and biaxial d] None of the above 2. Peripheral sensitization of the median nerve inducing elbow pain would be identi ed by? a] Symptom reproduction on active median nerve neurodynamic tests b] Symptom reproduction on passive median nerve neurodynamic tests c ] Local pain on palpation of the median nerve at the elbow d] All of the above 3. What are the approximate normal ranges of forearm pronation and supination in women: a] 110° and 90° b] 90° and 80° c ] 80° and 90° d] 60°and 70° 4. Possible entrapment sites for the median nerve at the elbow include: a] Ligament of Struthers, carpal tunnel, and pronator teres b] Cubital tunnel, carpal tunnel, and pronator teres e 12
5
c ] Ligament of Struthers, bicipital aponeurosis, and pronator teres d] None of the above 5. Name possible entrapment sites for the branches of the radial nerve at the elbow: a] Triceps tunnel b] Supinator tunnel c ] Radial tunnel d] b and c 6. Name possible consequences of ulnar nerve compression at the elbow: a] Sensory loss in the C7 dermatome b] Weakness of the abductor digiti minimi and sensory loss at the tip of the fth nger c ] Positive reverse Phalens test d] Positive ulnar nerve neurodynamic test 7. The most common cause of elbow pain in children under 10 years is: a] Rheumatoid arthritis b] Panner disease (osteochondrosis) c ] O sgood schlatters disease d] Lateral epicondylalgia 8. A baseball pitcher reports posterior elbow pain associated with end-range elbow extension movement. Treatment could include: a] O lecranon rotational mobilization with movement b] Ultrasound c ] Rest and splinting d] None of the above
M a n a g e m e n t o f e lb o w d is o rd e rs
9. You suspect a compressive neuropathy of the posterior interosseous nerve. Describe the area of sensory examination to support this: a] Lateral elbow b] Dorsum of the wrist c ] C7 dermatome d] None of the above 10. Contraindication to extension/ adduction grade IV at the elbow should include: a] Pain b] Joint stiffness on elbow exion c ] Dif culty to relax d] Laxity of the lateral ligament complex 11. Manual examination of the elbow should include: a] All potential contributing factors b] Articular structures c ] The humeroulnar joint, radiohumeral and radioulnar joints d] Movement impairments 12. Barriers to recovery from elbow pain include: a] Psychological status b] Job stress c ] Pain coping styles d] All of the above 13. Chronic lateral epicondylalgia is: a] A lost cause b] A multisystem problem c ] Rarely helped by manual therapy d] Always musculotendinous in origin 14. Name the tests to ‘prove’ the elbow unaffected in a low grade elbow pain condition: a] Extension/ abduction and extension/ adduction b] Supination and pronation overpressure c ] a and b d] Flexion and extension overpressure
16. Symptom from a remote source are likely to be: a] Localized, de ned, precise b] Vague, spreading medially c ] Associated with speci c elbow movements d] None of the above 17. The risk of myositis ossi cans is: a] Reduced by judicious, thoughtful and controlled techniques b] Reduced by high velocity thrust techniques c ] Reduced if pain-free, gentle techniques are employed d] a and c 18. Examination of the local articular structures in the composite elbow includes the: a] Radioulnar joint b] Radiohumeral joint c ] H umeroulnar joint d] All the above 19. Strengthening exercise for lateral epicondylalgia are: a] Contraindicated b] Focused on the pronator muscles c ] Aimed to minimize a deconditioning response to pain d] None of the above 20. A patient presents with diffuse lateral elbow pain, without local signs of dysfunction. Describe the structures you should examine in this case? a] Remote structures b] The radiohumeral joint c ] The lateral ligament complex d] None of the above
15. Mobilization with movement involves: a] Pain-free accessory glide with active or passive movement b] Pain-free accessory glide followed by muscle contraction c ] Painful accessory glide followed by active movement d] Painful accessory glide followed by muscle contraction e 13
6
Manag e me nt o f wris t and hand dis o rde rs
O ne or more of the answers maybe correct. 1. The tactile-kinaesthetic system is concerned primarily with: a] Movement b] Co-ordination c ] Feeling d] Body image 2. According to Moseley (2008), in patients with chronic pain, a relationship exists between: a] Pain intensity, loss of movement and fear avoidance b] Cortical re-organization, proprioception and loss of feeling c ] Pain description, muscle strength and pain inhibition d] Pain intensity, tactile acuity and cortical reorganization 3. Which ‘joints’ can be differentiated during painful wrist pronation? a] Inferior radioulnar and radiocarpal b] Inferior radioulnar, radiocarpal, mid carpal [intercarpal] and carpometacarpal c ] The movement only involves the radioulnar joints d] Inferior radioulnar, radiocarpal, mid carpal, carpometacarpal, metacarpophalangeal 4. Painful and debilitating musculoskeletal conditions are a combination of which of the following mechanisms? a] In ammation, nerve injury, fear b] Ischemia, complex regional pain, yellow ags e 14
c ] Input, processing, output d] Phantom pain, sympathetic pain, mechanical pain 5. Which two of the following features best corresponds to nociception? a] A strong relationship between symptoms and mechanical stimuli b] Associated tissue changes such as swelling and soft tissue thickening c ] Spontaneous pain d] Numbness and night pain 6. Dequervain’s disease is tenosynovitis of the tendon sheaths of: a] EPL and ECR b] ABD PL and EPB c ] EPL and ABPL d] EPL and EPB 7. Wartenberg’s disease or Cheiralgia parasthetica is a sensitive neuropathy of: a] The musculocutaneous nerve b] The ulnar nerve in G uyon’s canal c ] The super cial branch of the radial nerve d] The C5 Nerve root 8. Volkmann’s ischaemic contracture results in: a] Thoracic outlet syndrome b] G angrene of the hand c ] Avascular necrosis of scaphoid d] Retraction of the forearm exor muscles
M a n a g e m e n t o f w ris t a n d h a n d d is o rd e rs
9. According to source, the ideal ranges of movement at the wrist are: a] exion 80 degrees, extension 70 degrees, ulnar deviation 35 degrees, radial deviation 20 degrees pronation 85 degrees supination 90 degrees b] exion 90 degrees, extension 90 degrees, ulnar deviation 35 degrees, radial deviation 20 degrees pronation 90 degrees supination 90 degrees c ] exion 85 degrees, extension 80 degrees, ulnar deviation 35 degrees, radial deviation 20 degrees pronation 90 degrees supination 90 degrees d] exion 85 degrees, extension 85 degrees, ulnar deviation 20 degrees, radial deviation 10 degrees pronation 90 degrees supination 90 degrees 10. The cutaneous supply of the median nerve include: a] The ball of the thumb b] The palmar aspect of thumb, index, middle and half the ring nger c ] The dorsal aspects of the distal phalanx of the thumb, index, middle and half the ring nger d] The anterior aspect of the forearm 11. Which of the following are features of tendinopathy of the wrist? a] Crepitus with movement of the ngers b] Swollen in amed sheath c ] Pain with gripping d] H istory of overuse 12. Examples of prehensile function are: a] Press ups b] O pening a bottle c ] Waving d] Threading a needle 13. To differentiate De Q uervain’s tendinopathy from radial nerve sensitivity with the elbow in extension, the thumbs in exion and adduction and with the wrist in ulnar deviation add and release: a] Forearm pronation b] Wrist exion c ] Shoulder girdle depression d] Cervical contra lateral lateral exion
14. The super cial radial nerve at the wrist and hand can be palpated: a] O ver the scaphoid tubercle b] O ver the dorsum of the index nger c ] In the ‘anatomical snuff box’ d] At the lateral border of the radius just proximal to the radial styloid 15. Mobilize the mid carpal ‘joint’ into extension by placing: a] Thumbs against the dorsal aspect of the proximal row of carpal bones and index ngers against the palmar aspect of the distal row of the carpal bones b] Thumbs and index ngers on the distal row of the carpal bones c ] Thumbs and ngers on the proximal row of the carpal bones d] Thumbs against the palmar aspect of the distal row of carpal bones and index ngers against the dorsal aspect of the proximal row of the carpal bones 16. Intercarpal horizontal extension is produced by: a] Adducting the carpal bone b] Spreading the palm c ] Pulling on the hand d] Flexing the wrist 17. According to Roston & Wheeler-H aines (1947) to produce cavitation of the MCP joint requires, on average a distraction load of: a] 0.5 kg b] 90 kg c ] 8.3 kg d] 10 kg 18. Stabilization of wrist and hand function should include dissociation of: a] ECRB/ ECRL from FCR b] Lumbricals and interossei from long exors and extensors c ] Carpal mobility from wrist mobility d] Elbow movement from wrist movement 19. Manual therapy has a role to play in peripheral neuropathy and should include which of the possibilities as treatment options: a] Accessory movements on entrapment sites in neural tension b] Nerve sliders in the functional position c ] Cervical gliders in speci c ULNT d] Thoracic mobilization in slump position e 15
Manag e me nt o f wris t and hand dis o rde rs
20. It is possible to modulate nociceptive antalgic activity by: a] Staring at the hand b] Wearing pressure gloves c ] Crossing the arms d] Neglecting the hand
e 16
Manage me nt of hip dis orde rs
O ne or more of the answers maybe correct. 1. Which of the following structures are likely to refer pain into the groin? a] Lateral femoral cutaneous nerve b] L5 S1 disc c ] Patellofemoral joint d] Pubic symphysis 2. Structural femoroacetabular impingement is associated with: a] G roin pain b] Lack of decelerating force in the super cial gluteus maximus c ] Boney exostosies on the acetabulum or femoral neck d] H ypermobility in exion 3. Iliotibial tractitis may be associated with: a] Lateral hip pain b] Repeated extension / rotation activities such as jogging c ] O veractive tensor fascia lata d] Inhibited piriformis 4. A patient with degenerative osteoarthritis may be expected to complain of: a] G eneralized groin pain b] Pain relief on weight-bearing c ] Restriction in multiple movement directions d] Most exible rst thing in the morning 5. Meralgia paraesthetica: a] Is caused by entrapment of the inguinal nerve
7
b] Produces burning pain on the inside of the thigh c ] Produces symptoms with longer periods of sitting, squatting, increased walking, standing d] Is often associated with obesity 6. The segmental stabilizers are: a] O ne-joint muscles b] Short c ] Direction speci c d] Aligned in the direction of primary joint movement 7. A maximal contraction recruiting only tonic muscle bres: a] Will best be achieved by asking the patient to contract the muscle slowly b] Will best be achieved by asking the patient to contract the muscle with at least 40% of maximal voluntary contraction c ] Will show signs of fatigue by approximately 30 seconds d] May be facilitated by increasing proprioceptive input 8. Patients with the following disorders may complain of pain during exion and exion/ adduction activities: a] Structural Femoro-acetabular Impingement (Pincer or Cam) b] Excessive Anterior G liding Dysfunction c ] Excessive Posterior G liding Dysfunction d] Piriformis syndrome e 17
Manag e me nt o f hip dis o rde rs
9. The following parameters are helpful in assessing ideal alignment: a] The patella is aligned over the second metatarsal b] A line joining the ASIS and PSIS is horizontal or tilted 5° posteriorly c ] The foot is externally rotated 15°–20° d] The knee fold is horizontal (or not more than 10° higher laterally) 10. Apparent hip lateral rotation with toeing-out may be related to which one of the following structural disorders: a] Coxa valgus b] Femoroacetabular impingement c ] Femoral retroversion d] Tibial torsion 11. Which of the following parameters would be acceptable for active range of hip movement: a] Flexion 110°–125° b] Extension 10°–15° c ] Medial rotation (measured in 90° exion) 30°–45° d] Lateral rotation (measured in 90° exion) 40°–60° 12. When testing the posterior gluteus medius for optimal length change: a] Active range of movement should approximately equal passive range b] The heel should reach a level approximately 2.5 cms above the plinth (women) or should reach the plinth (men) c ] The contraction should be held without fatigue for 30 seconds d] The waiste should remain in contact with the plinth 13. For ideal performance of the modi ed Thomas’ test: a] The patient’s lumbar spine should lie at on the plinth b] During hip extension on the test side the hip should remain in neutral abduction/ adduction c ] The thigh should come to rest on the plinth with the knee exed and the hip in 15° adduction d] The thigh should come to rest on the plinth with the knee extended and the hip in abduction e 18
14. During the exion/ adduction examination test: a] G roin pain should not be elicited in the normal hip b] Increased pain caused by tilting the ilium posteriorly in a symptomatic position implicates the sacroiliac joint c ] Increased pain caused by tilting the ilium anteriorly in a symptomatic position implicates the lumbar spine d] Pain from a structural femoroacetabular impingement but not from a functional anteromedial impingement may be expected 15. Restricted posterior and lateral gliding: a] May be responsible for gross restriction of physiological exion b] May be implicated if a SLR performed with simultaneous anteroposterior pressure on the femoral head goes further than the classical SLR procedure c ] May be due to overactivity in the posterior hip joint muscles d] May be associated with excessive anterior gliding 16. The test for excessive anterior gliding in prone: a] Requires the patient to extend the externally rotated hip 10°–15° b] Is positive if the trochanter moves towards the plinth c ] Requires good xation of the ilium on the test side d] Is positive if the patient internally rotates the hip 17. Strong lateral accessory movement as a passive mobilising technique may be ideal for the treatment of: a] Medial migratory presentations of osteoarthritis b] ‘Up and out’ migratory presentations of osteoarthritis c ] Excessive posterior gliding dysfunction d] Restricted hip exion 18. Which of the following statements are accurate? a] The segmental stabilizers should be tonically recruited to stabilize excessive gliding movements
M a n a g e m e n t o f h ip d is o rd e rs
b] As a multi-joint global mobilizer psoas is often overactive or short and requires inhibition and lengthening techniques c ] Recruiting/ shortening the global stabilizers and inhibiting/ lengthening the global mobilizers may help painful hypermobility disorders d] Recruiting the global stabilizer is much more important than correcting posture or correcting movement patterns
20. Which of the following techniques may be important in the treatment of athlete’s groin: a] Recruitment of transversus abdominis b] Stretching of the painful adductors c ] Surgical techniques to suture and stabilize the abdominal fascia d] Avoidance of forceful rotatory and ‘stop and go’ activities in early rehabilitation
19. When physiological movement is restricted and non-irritable, treatment may be directed at: a] Lengthening the fascia b] Inhibiting/ lengthening the global Stabilizers c ] Mobilizing the joint d] Recruiting the segmental stabilizers
e 19
Manag e me nt o f kne e dis o rde rs
O ne or more of the answers maybe correct. 1. The ‘Bone and Joint Decade’ is raising awareness to: a] The necessity of an active lifestyle to prevent non communicable diseases as osteoarthritis of the knee b] Sedentary life styles are of consequence with regards to non communicable diseases only to the elderly population c ] Poor habits in diet and activity levels in adolescent ages have no impact on an individual’s health in future d] Physiotherapy is already suf ciently used in the treatment of osteoarthritis of the hip or knee in the UK 2. In order to improve tness levels physiotherapists should consider: a] Aerobic capacity b] Muscle functions as strength, endurance, power c ] Balance d] Agility and exibility 3. To maintain its stability the knee joint is mainly dependent upon the following structure: a] Menisci b] Ligaments c ] Muscle functions e20
8
d] G liding and rolling mechanisms of the knee joint e ] All of above interacting together 4. The main functions of the popliteus muscle are: a] Internal rotation of the tibia in relation to the femur b] Monitoring subtle movement in the transverse and frontal plane of the knee c ] Controlling anterio-posterior movement of the lateral meniscus d] None of above 5. Alignment of the trunk/ pelvis/ hip area and foot/ ankle complex are: a] Not relevant in motor patterns of the knee b] In uenced by abductors and lateral rotators of the hip c ] In uenced by intrinsic muscles of the foot d] In uenced by quadriceps, hamstrings, gastrocnemius and popliteus muscles 6. O steoarthritis of the knee: a] Will only be diagnosed by x-ray changes b] Clinical symptoms do not play a role in diagnosis c ] A direct correlation between X-ray changes and symptoms and disability is not demonstrated d] Needs to be treated with rest
M a n a g e m e n t o f kn e e d is o rd e rs
7. Treatment guidelines for osteoarthritis of the knee include: a] O ptimising movement functions as mobility, motor control, coordination b] Restoring overall functional capacity and performance c ] Enhancement of tness and wellbeing d] Prevention of recurrences of pain and disability 8. OA related research has demonstrated that: a] Active exercises may have bene cial effects on treatment outcomes b] A combination of active and passive movement show better therapeutic outcomes than either form of treatment alone c ] No movement has any effect d] Anterior thigh pain may be a clinical prediction rule for treatment of the hip in cases of knee osteoarthritis 9. Anterior knee pain as an expression of a patello femoral pain syndrome: a] May need to be treated with corrective tapes alone b] Corrective tapes are an option to train the VMO : VL relationships in a painfree condition c ] Passive mobilizations of the patella and soft tissue techniques may be considered as a treatment option in acute and subacute phases of the syndrome d] Studies demonstrate a correlation between improvement of the EMG timing of the vasti medialis and lateralis the quadriceps muscles and pain reduction 10. Subjective examination of the knee should encompass: a] Q uestions about the areas of symptoms b] Q uestions related to levels of disability c ] Q uestions related to onset of the disorder, being traumatic or of spontaneous onset d] Screening questions related to medical disease and health 11. Physical examination – observation of alignment: a] Is not important b] Is relevant to monitor possible risk factors for knee injury
c ] Should only include the Q -angle (quadriceps-angle) d] Should include six measurements/ observations 12. Active tests of the knee: a] Are only performed in supine b] Include only exion, extension and rotation movements c ] Should be adapted to the current levels of activity of the patient d] May include movement combinations as for example F/ Ab, F/ Ad, F/ MR, F/ LR, E/ AB, E/ AD 13. Muscles tests may be performed with the following objectives: a] Symptom reproduction b] Muscle strength, endurance, coordination and recruitment patterns c ] Muscle length tests d] All of above 14. Screening of other movement components in the examination of knee disorders may include: a] Examination of the hip b] Examination of the lumbar spine c ] Examination of neurodynamic functions d] Examination of the sacroiliac joint 15. Neurodynamic tests for the knee area may include: a] O nly tests for the sciatic nerve b] O nly tests for the femoral nerve and its branches c ] Sciatic nerve with emphasis on the tibial nerve and communal peroneal nerve d] Femoral nerve, saphenous nerve, infrapatellar branches 16. Movement diagrams of passive movement tests: a] G ive inconsistent results and should not be used anymore b] Are confusing c ] Are a means of communication d] Are a means of learning the skills of palpation e21
Manag e me nt o f kne e dis o rde rs
17. O rthopaedic testing of menisci and ligaments: a] Are a standard procedure of examination b] Are only performed if indication of trauma to the structures is present c ] Will frequently be incorporated in the standard movement examination as outlined in the Maitland Concept of Manipulative physiotherapy d] Many tests have an acceptable sensitivity 18. Treatment of knee disorders: a] Is related to the restoration of functional capacity b] Should encompass guiding patients to a health living and life-style c ] Passive mobilization may play a core role in acute and subacute phases of pain d] Motor control enhancement strategies are often a part of treatment planning 19. Passive mobilizations are being selected a] Based on the behaviour of pain, tissue resistance and motor reactions of physiological movements
e22
b] Based on the behaviour of pain, tissue resistance and motor reactions of accessory movements c ] Based on current levels of pain and mobility d] O nly in cases of stiffness, not in cases of hypermobility or instability 20. Compression may be added to the joint surfaces while treating with passive movement: a] This is a novel contribution of Maitland to the world of manipulative physiotherapy b] In cases of a pain occurring ‘through the range of movement’, pain occurring mainly when loading the structures concerned and the pain increases under compression c ] In cases in cases of acute in ammation of the joint d] In early postsurgical phases
9
Manag e me nt o f fo o t and ankle dis orde rs
O ne or more o the answers maybe correct. 1. H ow many bones do the oot and ankle contains? a] 42 b] 52 c ] 28 d] 25 2. What is the main unction o the distal tibiof bular syndesmosis? a] Provide stability or the ankle b] Prevent movement o the ankle c ] Restrict movement o the STJ d] Provide stability or the knee 3. What is the normal range o motion o the subtalar joint? a] 100 degrees b] 20 degrees c ] 10 degrees d] 30 degrees 4. What is the predominant motion plane o the midtarsal joint? a] Frontal plane b] Variable between subjects c ] Sagittal plane d] Transverse plane 5. H ow many degrees the f rst metatarsophalangeal joint dorsi ex during the pre-swing o the gait cycle? a] 70 b] 45
c ] 55 d] 110 6. What is the estimated prevalence o the plantar heel pain in general population? a] 10% b] 50% c ] 2% d] 15% 7. H ow many people develop chronic ankle instability a ter an acute ankle sprain? a] 80–90% b] 2–4% c ] 10–20% d] 50% 8. What is the role o the subjective examination? a] It is not necessary. b] It orms a basis or the clinical reasoning process. c ] It completes the in ormation gathered during the physical examination. d] It is important or legal purposes. 9. Which alternatives o the ollowing suggestions belong to the subjective examination? a] Symptom area b] Movement testing c ] Behaviour o the patient according to the disorder d] H istory o the symptoms e 23
Manag e me nt o f fo o t and ankle dis o rde rs
10. Which o the ollowing phases are included in planning o the physical examination? a] Functional demonstration b] Expressing hypotheses c ] Re ection on the subjective examination d] Planning physical examiantion procedures 11. Which o the ollowing alternatives represent hypotheses categories? a] Prognosis b] Direction o impairment c ] Source o the symptoms d] Mobilization 12. H ow many phases are there in physical examination o the oot and ankle? a] 10 b] 7 c] 3 d] 5 13. H ow is the position o the oot and ankle standardized during observation in non-weight bearing? a] Patient is standing with the eet acing orwards b] Patient is in relaxed prone lying position c ] Talocrural joint is in neutral dorsi exion d] Subtalar joint is positioned in a neutral position 14. What special eature observation o the gait provides physical examination o the oot and ankle? a] Timing relationship o the movements during gait cycle b] Mobility o the joints c ] Provocation test d] Passive mobility o the joints 15. What is the aim o the passive movement testing? a] Provoke symptoms b] Identi y movement impairments c ] Identi y direction o impairment d] Identi y motor control impairment
e24
16. Which physiological movement directions o the ollowing alternatives are related to passive movement testing o the oot and ankle? a] Longitudinal caudad b] Anteroposterior movement o the talus c ] Plantar exion d] Supination 17. Which movement components o the ollowing alternatives are related to hind oot supination? a] Plantar exion b] Inversion c ] Lateral rotation d] Medial rotation 18. What is the primary intervention in movement impairments? a] Motor control exercises b] Medical treatment c ] Restoring physiological movement with mobilization and/ or exercises d] Foot orthoses 19. What is the primary intervention in motor control impairments? a] Medical treatment b] Foot orthoses c ] Therapeutic exercises d] Mobilization and manipulation 20. What is basis o the selection o the exercises in motor control impairment? a] Strength b] Endurance c ] Direction o the impairment d] Mobility
Ve rte bral manipulatio n
Question Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 1
b
c,d
b
d
b
c
b,d
a
c
2
d
a,b
a
b
d
d
a,c
a,b,c,d
a
3
c
b,d
a
a,b,c,d
c
b
a,b,c
e
c
4
c
a,b
d
d
c
c
a,c
a,b,c
b
5
d
b,c
c
a,b,c,d
d
a,b
c,d
b,c,d
c
6
a
a
a
b
b
b
a,b
c
a
7
b
a,c,d
d
a,c
b
c
a,d
a,b,c,d
c
8
a
a,c,d
d
d
a
d
a,b,c
a,b,d
b
9
a
a,b,c,d
b
a,b,c,d
d
a
a,d
b,c,d
a,c,d
10
a
a,b
c
a,c
d
a,b,c
c
a,b,c,d
b,c,d
11
b
a
a
a,b,c,d
a
a,b,c,d
a,b,c,d
b,d
a,b,c
12
d
a,b,c,d
d
c
d
b,d
a,c
c,d
b
13
c
c,d
c
ab
b
c,d
c
d
d
14
c
c
a,b,c,d
c
c,d
b
a,b,c,d
a
15
c
d
c
a
a
a,b,c,d
c,d
a,b,c
16
d
a
d
d
b
b,c
c,d
c,d
17
a
c
a,b,c,d
d
c
a,d
b,c,d
a,b,d
18
b
d
a,b,c,d
d
b
a,c
a,b,c,d
c
19
c
d
a,b,c,d
c
a,b,c,d
a,c
a,b,c
c
20
c
d
a
a
c
a,c,d
a,b
c
e 25
Se lf-manag e me nt s trate g ie s : Complianc e and be havio ural c hange
Appendix 1
Elly H engeveld
C H AP TE R C O N TE N TS Comp lia nc e
559
Cognitive –b e ha vioura l a p p roa c h
559
Ha b its d on’t c ha nge ove rnight – p ha s e s of c ha nge
560
Comp lia nc e e nha nc e me nt s tra te gie s
561
Conc lus ion
563
As stated at various times in this book, in many clinical presentations passive mobilization can be considered as a kick-start to active movement. There ore manipulative physiotherapists will o ten suggest sel -management strategies complementary to the passive mobilizations, once they have established the sources o the movement dys unctions and the mechanisms o the nociceptive processes. Sel -management strategies should ref ect the clinical stages and syndromes as outlined in Chapter 1 and may ollow di erent purposes:
• Sel -help strategies to control pain and promote • • • •
a sense o wellbeing Prevention o new episodes o symptoms Increase general physical tness and normalize activity levels Increase bodily awareness and relaxation Rehabilitation o movement impairments such as joint mobility, neurodynamics and muscle unction.
The provided instructions, suggestions and exercises are especially relevant in the process o secondary prevention o disability due to pain. Currently this concept receives much attention in 558
the treatment o spinal disorders as, over a period o two decades until the end o the 1990s, the prevalence o chronic disability due to low back pain increased substantially in industrialized countries (Waddell 2004). It is suggested that psychosocial actors (e.g. ear avoidance behaviour, belie s) as well as con using in ormation by clinicians are contributing elements in this development (Kendall et al. 1997). In particular, a sense o helplessness, which easily evolves into hopelessness, may be an important contributing actor which should be prevented in any acute pain state (H arding et al. 1998). There ore it may be concluded that it is essential in an early stage o treatment to guide patients to a sense of control over their wellbeing with sel -management strategies (Roberts et al. 2002). An increasing number o studies incorporating variables with locus o control (Rotter 1966) or sel e cacy belie s (Bandura 1989) are being integrated in physiotherapy research (Crook et al. 1998, Frost et al. 2000, Roberts et al. 2002). It is important to realize that the sense o control may change over the period o time in which a patient su ers rom pain and restricted unctioning. It is possible that a sense o helplessness increases with ongoing states o pain and disability. It is crucial that the physiotherapist discovers in an early stage o examination whether or not patients (still) have a sense o control over their pain and perceived limitations o daily li e and which strategies they employ to achieve this. Physiotherapists with their speci c pro essional expertise have numerous possibilities to guide
C o g n itive –b e h a vio u ra l a p p ro a c h
patients towards a sense o control over their pain or wellbeing, as or example:
• • • • • •
repeated movements automobilizations relaxation strategies body and proprioceptive awareness muscle recruitment exercises other pain-management strategies (e.g. hot packs, cold packs).
Co mplianc e In the process in which the physiotherapist provides the patient with sel -management strategies, the concept o compliance enhancement plays an important role. Compliance is described as the degree to which the behaviour o a client coincides with the recommendations o the clinician (Schneiders et al. 1998). At times the word ‘adherence’ is used as well. H owever, both terms are somewhat awkward, as they indicate too strongly an authoritarian onedimensional clinician–patient relationship in which the patient has to ollow the orders o the clinician in a passive role (Kleinmann 1997). Within this context a ocus on the change o un avourable (movement) behaviours in daily li e is recommended, hence taking a cognitive– behavioural perspective in which the term ‘compliance’ is associated with a more active role or the patient.
Barriers to compliance It seems that compliance to medical or physiotherapy interventions ranges rom 15 to 94%, depending on the way the studies were per ormed (Sluys & H ermans 1990, Ferri et al. 1998). There appear to be di erent opinions as to why patients would not ollow the advice, recommendations or exercises o a physiotherapist. It appears that many physiotherapists contribute this to patients’ lack o motivation or discipline (Kok & Bouter 1990). H owever, a pro ound study indicates several categories o barriers perceived by patients to the suggested behaviours (Sluys 1991):
• Barriers to incorporating the suggestions and exercises into daily li e (e.g. exercises in supine cannot be per ormed in a work setting; lack o time to exercise every day or 30 minutes;
directive goal setting such as ‘you should take more time off for yourself’; too many instructions and suggestions in one treatment session). • Lack o positive eedback (insecurity as to whether the exercises are per ormed in the correct manner; no experience i the exercises truly are help ul). • Sense o helplessness (the patient does not experience an ability to inf uence the situation positively).
Co g nitive –be havio ural appro ac h Based on these perceived barriers it is suggested that the therapist ollows a cognitive–behavioural approach to the education o a patient, with an in ormation plan incorporated in the overall treatment plan (Sluys 2000). In this approach, ocussing on the change of unhelpful habits in movement behaviour is recommended (H arding & Williams 1995). H owever, requently physiotherapists seem to choose a somewhat one-dimensional approach to treatment (Fig. A1.1) in which no speci c behavioural or communication strategies are pursued. In a one-dimensional approach it is assumed that trust to move as well as the levels o activity and participation normalize as a consequence o interventions with objectives such as pain reduction and normalization o movement impairments. Furthermore, it appears that it is expected that a single instruction o an exercise leads to a lasting change in behaviour, in which the suggested interventions are employed at all the moments in which this seems necessary (H engeveld 2000). Within this context there is the criticism that physiotherapists seem to pre er to tell a patient how to move in daily li e, rather than One-dimensional approach to management = classical management in teaching (PT; Medicine; OMT) Pain reduction
+
Impairment improvement
Not much awareness on communication strategies, collaborative goal setting, roles, ‘art’ of assessment and reassessment needed
Activity, Participation
Understanding of preventive measures + active coping and doing this at adequate moments Trust in use of body
Fig ure A1.1 • One-dimensional approach to treatment. Reproduced by kind permission from Hengeveld (2000).
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guiding them to experience this (Treves 1998). This may hinder some patients in regaining trust in daily li e activities.
success ully implement the suggested behaviours in daily li e routines:
Habits do n’t c hang e o ve rnig ht – phas e s o f c hang e
per ormed as long as the contact between the physiotherapist and patient exists • Long-term compliance: the patient maintains the behaviour a ter the completion o treatment.
H abits rarely change overnight and people will go through phases in which the intention may exist to change the behaviour, but distractions and tasks in daily li e, as well as other habits, may hinder the patient rom automatically and consequently incorporating the suggested behaviour immediately. It has been postulated that people go through various stages o motivation in a behavioural change (Prochaska & DiClemente 1994, Van der Burgt & Verhulst 1997, Dijkstra 2002) (Table A1.1). It can be summarized rom these models that a person goes through various phases be ore being able to
• Motivation development • Short-term compliance: the behaviour is
Motivational phas e • In this phase the patient o ten needs educational strategies with regard to, or example, the positive e ects o movements on osteoarthritic processes or discal problems. Education with regard to neurophysiological pain mechanisms may also be necessary in this phase.
Table A1.1 Models of stages of change in behaviour and suggested interventions by physiotherapist
Prochaska & DiClemente (1994) – Stages of change model
Van der Burgt & Verhulst (1997)
Dijkstra (2002)
1 Precontemplation: in this phase changing behaviour is not considered 2 Contemplation: change of behaviour is considered; however no concrete plan exists 3 Preparation: plans are developed actively to change the behaviour in the short term 4 Action: phase in which the desired behaviour is performed 5 Consolidation: the desired behaviour is maintained and fallbacks in behaviours are prevented
1 Openness: (PT interventions: Investigation of beliefs and expectations. Information on usefulness of movement with e.g. discal problems or osteoarthritis) 2 Understanding and comprehension of the information: (often neglected inphysiotherapy: have the patientsunderstood and do they consider the given information useful?) 3 Intention (development of plans) 4 Capability (having the capacity) The exercises should be simple and if possible give a sense of success 5 Action: change of behaviour with respect to incorporation of exercises and suggestions into DLA 6 Maintaining behaviour: continuation with the behaviour after completion of therapy
1 Non-motivated: (in this phase a patient needs information and education with regard to the use of exercises to enhance wellbeing. Patients need to experience directly that the exercises contribute to wellbeing. Attention to the quality of the educational processes and reassessment of cognitive objectives is necessary – i.e. has the patient understood what the PT wanted to explain?) 2 Consideration if suggested behaviour is useful (allow time for the patient to ask questions concerning the information given in previous sessions) 3 Preparation (development of plan and clear intentions) Clear instructions needed, when to do the exercises in daily life, asking when it was possible to do the exercises and when dif culties existed, monitoring if the suggested interventions brought the desired results 4 Experimenting with the actions in various daily life situations 5 Action: change of behaviour with respect to incorporation of exercises and suggestions into DLA
Adapted from Prochaska & DiClemente (1994), Van der Burgt & Verhulst (1997), Dijkstra (2002).
560
C o m p lia n c e e n h a n c e m e n t s tra te g ie s
• In order to be able to provide the
•
•
• •
•
educational strategies success ully, the therapist rst needs to determine the patient’s belie s with regard to movement and to ascertain i the patient is receptive to new in ormation. Further, it is suggested that the therapist ollows an initial process o collaborative goal setting be ore starting o with explanations and educational strategies (Brioschi 1998). A ter the educational strategies the therapist should evaluate i the patient has understood and can make sense o the in ormation. Next, over a period o several sessions, it is essential to give the patient su cient time to ask questions and seek clari cations. In this phase it is essential that the patient can experience that movement and relaxation may contribute to wellbeing. Perceived success and a sense o achievement appear to be relevant actors in compliance to exercises (Courneya et al. 2004). Reassessment o subjective ndings and physical examination tests will contribute to a sense o success.
the patient has been able to per orm the exercises and done them at appropriate moments. Patients may do the exercises at xed times o the day; however, at those moments where pain increases they o ten stay in the habituated behaviour o resting or taking medication, rather than trying out the suggested interventions. It is essential that the physiotherapist does not consider this as a lack o motivation but as a help-seeking behaviour which has not yet been habituated. The style o communication may inf uence this process o learning and experimenting with exercises in various daily li e situations substantially.
Long-term compliance • The patient maintains the behaviour a ter the • • • •
Short-term compliance • The phase o short-term compliance begins •
•
•
•
once the patient starts to experiment with a ew simple exercises in daily li e. It should not be expected that the desired e ect is immediately experienced or that the patient per orms the exercises at all the appropriate moments in daily li e. O ten it is better to start o with one or two exercises and to check i they are help ul be ore other exercises are integrated into the sel -management programme. Regular contact between the physiotherapist and patient is essential, in which the patient can ask questions and the physiotherapist may give corrections or suggestions. The physiotherapist may need to motivate the patient to ‘hang in’ with the exercises, even i no results are experienced yet.
During the subjective reassessment in ollow-up sessions, the physiotherapist needs to nd out i
•
completion o therapy (long-term compliance). This phase needs to be well prepared. It usually takes place towards the end o the treatment series and is completed with the nal analytical assessment. Collaboratively with the physiotherapist, the patient needs to anticipate uture situations in which pain is likely to recur. The physiotherapist and patient discuss and repeat the behaviours which may be use ul to inf uence the discom ort i the pain situation recurs. A repetition o prophylactic measures is o ten help ul in this phase as well.
Co mplianc e e nhanc e me nt s trate g ie s In order to develop meaning ul exercises or a patient, the physiotherapist may ollow an algorithm o actions and decisions:
• Find the sources o the movement dys unction in examination and reassessment procedures. • Make a decision regarding treatment goals and interventions colaboratively with the patient. • In the selection o interventions, make a decision as to which physiotherapist-directed interventions (e.g. passive mobilizations) and 561
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which sel -management strategies are to be employed. • In the selection o sel -management strategies the physiotherapist should consider the objectives o the strategies i the patient has to do the exercises or a de nite or inde nite period o time. • To those patients whose main complaint is pain, it is essential to teach coping strategies prior to the employment o interventions which should inf uence contributing actors (e.g. posture, general tness). • With these coping strategies patients may perceive a sense o success and control over their wellbeing, and hence may develop trust to per orm exercises which they initially believed to be harm ul.
Integration of the exercis es into daily life s ituations • In situations in which the patient needs to
•
•
Selection of coping s trategies to control pain and wellbeing • The selection o coping strategies is normally based on the di culties in daily li e activities as perceived by the patient. • In this case in ormation rom the subjective examination is requently a more decisive actor in decision making than data rom inspection or active movement testing. • In particular, data rom the ‘24-hour behaviour’ o symptoms and at times the precipitating actors o the history may be very in ormative (Chapter 1). It is important to know in which ways the patient is capable o inf uencing pain ul daily li e activities. • In order to be able to make a decision with regard to meaning ul coping strategies, it is essential that the physiotherapist deliberately seeks in ormation in the above-mentioned phases o subjective examination.
Exa mp le A woman who works in a actory at a sewingmachine develops pain in the thoracic area a ter 6 hours o work. Although in the physical examination she is shown to have a f attened thoracic kyphosis, her sel -management strategies to inf uence the pain are variations o repeated extension and rotation movements. 562
•
•
develop a new behaviour which inf uences wellbeing, it may be that the patient will need to employ this behaviour or a long period o time, sometimes or li e. There ore it is essential to provide simple, achievable exercises which are easy to incorporate in daily li e situations in order or them to become part o the habitual movement behaviour. Un ortunately, patients are o ten taught to per orm certain exercises lying supine, although the di culties they have with pain occur during working situations in, or example, sitting positions. In such cases it is possible that a sense o helplessness gradually develops, as the patient does not perceive a sense o success directly in the given working situation (‘I have tried physiotherapy, but nothing really helped’). It is essential not to teach a single intervention, but to work collaboratively with the patient on modi cations o the exercise, according to the demands o the various daily li e situations. The patient needs to know that the adaptations are not di erent exercises but are ‘variations on the same theme’. Notwithstanding cases such as postoperative management, in which it is anticipated that the exercises only need to be employed or a limited period, the patient may be provided with a ‘home programme’ to which time is allocated in the patient’s daily routine. H owever, i the patient starts to resume daily routines or returns to work, o ten it is use ul to seek collaboratively with the patient variations o the ‘home programme’ exercises which can be integrated into the busy schedules o daily li e.
Based on a literature study, the ollowing aspects o compliance enhancement are recommended to support the patient optimally to a lasting change in movement behaviour (H engeveld 2003):
• Follow a cognitive–behavioural perspective, in which it is acknowledged that habits in
C o n c lu s io n
behaviour do not change overnight with one intervention. Respect the various phases o behavioural change.
• Belie s with regard to the necessity o activities and movements in the treatment o pain need to be investigated.
• Follow an instruction and education plan, in which an awareness o all the instructions given during one session is necessary. Repeat the given in ormation over various sessions; give pieces o in ormation, rather than everything at once.
• Collaborative goal setting and conscious communication procedures are essential.
• O ne o the most essential goals o sel management strategies is guiding patients to a sense o control over their wellbeing (H arding et al. 1998).
• I a patient believes that moving may be harm ul when activities and work situations provoke pain, the physiotherapist may guide the patient with educational strategies complementary to passive mobilizations and other sel -management interventions. At times the physiotherapist may use the ollowing axioms in the educational process:
• Written in ormation as a mnemonic may enhance understanding. At times patients may do this by themselves. A ‘pain, activities and exercise diary’ may be incorporated. • Ensure that the exercises can be implemented in daily li e situations. Patients requently need to be provided with variations o the same exercises and should understand them as such. This is particularly important in those situations where a patient needs to develop a new behaviour, which may last or a long time, sometimes or li e. • Anticipation o di culties: a ter the selection and instruction o an exercise, the physiotherapist needs to discuss with the patient i and where di culties are anticipated. Certain exercises may be very use ul, but not during a given work situation. Collaborative problem solving or such a situation is essential and modi cations o the exercise need to be worked out. • At the completion o a treatment series, in order to enhance long-term compliance, urther anticipation o possible uture recurrences and their solutions needs to take place.
○ ‘It’s not what you move, but how you move’ (Sahrmann 1999).
○ ‘It’s not necessarily the work task, but the working style which provokes symptoms’ (Watson 1999).
• Take time to teach the exercises, rather than telling the patient what to do in the last ew minutes o a session. Allocate time or the patient to ask questions.
• Enhance positive eedback by per orming a reassessment a ter the exercise (sometimes only seeking in ormation about the sense o pain or wellbeing – ‘present pain’).
Co nc lus io n Be ore teaching an exercise the physiotherapist should go through the ollowing steps and questions:
• What are the goals o the exercises? • When should the exercises be employed in • • •
• In ollow-up sessions ask the patients during the subjective reassessment phase i they have been able to per orm the exercises and what the e ect was. Pose the questions in such a way that patients eel ree to say i they have orgotten the exercises. I this happens, it should not directly be attributed to lack o motivation or discipline.
•
daily li e? H ave I explained the objectives o the exercises to the patient? H ave I checked i the patient has understood? Were the exercises reassessed immediately a ter being per ormed? Did they contribute to a sense o success? Did I anticipate collaboratively with the patient i and when to per orm the exercises should di culties recur?
This appendix is adapted rom H engeveld, E. 2003. Compliance und Verhaltensänderung in Manueller Therapie. M anuelle Therapie, 7(3), 122– 132, with permission. 563
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References Bandura A: Perceived sel -e cacy in the exercise o personal agency, Psychologist 10:411–424, 1989. Brioschi R: Kurs: die therapeutische Beziehung. In Brioschi R, H engeveld E, editors: Leitung, Fortbildungszentrum Zurzach, Mai, 1998. Courneya KS, Friedenreich CM, Sela RA, et al: Exercise motivation and adherence in cancer survivors a ter participation in a randomized controlled trial: an attribution theory perspective, Int J Behav M ed 11:8–17, 2004. Crook P, Rose M, Salmon P, et al: Adherence to group-exercise: physiotherapy-led experimental programmes, Physiotherapy 84:366–372, 1998. Dijkstra A: H et veranderings asenmodel als leidraad bij het motiveren tot en begeleiding van gedragsverandering bij patienten, N TvF 112:62–68, 2002. Ferri M, Brooks D, G oldstein RS: Compliance with treatment – an ongoing concern, Physiother C an 50:286–290, 1998. Frost H , Lamb SE, Shackleton C: A unctional restoration programme or chronic low back pain, Physiotherapy 86:285–293, 2000. H arding VR, Williams ACDC: Extending physiotherapy skills using a psychological approach: cognitive– behavioural management o chronic pain, Physiotherapy 81:681–688, 1995. H arding VR, Simmonds MJ, Watson PJ: Physical therapy or chronic pain, Pain, Clinical Updates (IASP) VI:1–4, 1998.
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H engeveld E: Psychosocial Issues in Physiotherapy: M anual Therapists’ Perspectives and O bservations. M Sc Thesis, London, 2000, Department o H ealth Sciences, University o East London. H engeveld E: Compliance und Verhaltensänderung in Manueller Therapie, M anuelle Therapie 7:122–132, 2003. Kendall NAS, Linton SJ, Main CJ, et al: G uide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss, Wellington, New Zealand, 1997, Accident Rehabilitation & Compensation Insurance Corporation o New Zealand and the National H ealth Committee. Kleinmann A: In Fadiman A, editor: The Spirit Catches You and You Fall Down – A H mong C hild, her American Doctors and the Collision of Two Cultures, New York, 1997, Farrar, Strauss and G iroux. Kok J, Bouter L: Patientenvoorlichting door ysiotherapeuten in de eerste lijn, N TvF 100:59–63, 1990. Prochaska J, DiClemente C: Stages o change and decisional balance or twelve problem behaviours, H ealth Psychol 13:39–46, 1994. Roberts L, Chapman J, Sheldon F: Perceptions o control in people with acute low back pain, Physiotherapy 88:539–548, 2002. Rotter J: G eneralized expectancies or internal versus external control o rein orcement, Psychol M onogr 80:1–5, 1966.
Sahrmann S: Course on the assessment and treatment of movement impairments, Zurzach, Switzerland, 22–25 August 1999, 1999. Schneiders A, Zusman M, Singer KP: Exercise therapy compliance in acute low back pain patients, M anual Therapy 3:147–152, 1998. Sluys E: Patient education in physiotherapy: towards a planned approach, Physiotherapy 77: 503–508, 1991. Sluys E: Therapietrouw door Voorlichting – H andleiding voor Patiëntenvoorlichting in de Fysiotherapie, Amsterdam, 2000, Uitgeverij SWP. Sluys E, H ermans J: Problemen die patienten ervaren bij het doen van huiswerkoe eningen en bij het opvolgen van adviezen, N TvF 100:175–179, 1990. Treves KF: Understanding people with chronic pain ollowing whiplash: a psychological perspective. In G i ord L, editor: Topical Issues in Pain – W hiplash: Science and M anagement. Fear-Avoidance Beliefs and Behaviour, Adelaide, 1998, NO I G roup. Van der Burgt M, Verhulst H : Van therapietrouw naar zel management: voorlichting op maat, Fysiopraxis 12:4–7, 1997. Waddell G : The Back Pain Revolution, ed 2, Edinburgh, 2004, Churchill Livingstone. Watson P: Psychosocial Assessment, IMTA Educational Days, Zurzach, Switzerland, 1999.
Re c o rding
Appendix 2
Elly H engeveld
C H AP TE R C O N TE N TS Introd uc tion
565
As te ris ks
567
Cond itions
567
Some re ma rks with re ga rd s to re c ord ing
567
Re c ord ing of s ub je c tive e xa mina tion nd ings
568
Re c ord ing of p hys ic a l e xa mina tion nd ings
570
Ac tive move me nts
570
P a s s ive move me nts
572
Re c ord ing of tre a tme nt inte rve ntions
573
Informa tion, ins truc tions , e xe rc is e s , wa rning a t the e nd of a s e s s ion
574
Re c ord ing of follow-up s e s s ions
574
Re tros p e c tive a s s e s s me nt
574
Writte n re c ord s b y the p a tie nt
575
Conc lus ion
575
Key words Recording, reas s es s ment, SOAP notes
Intro duc tio n Assessment and treatment require an in-depth written record of the ndings and results at each
session. Ideally, documentation which is systematic, consequent and easy to (re-)read in a short time provides the physiotherapist with a framework that should lead the therapist throughout the overall therapeutic process. Systematic records serve as a mnemonic and a means of communication to other professionals. They support the physiotherapist in various ways:
• To re ect upon the decisions made • To control the actions taken • If necessary, to quickly adapt the therapy to a changing situation. H ence, written records are essential in the process of ongoing quality management. It is argued that many physiotherapists consider documentation of sessions as a necessary evil. As a consequence many records frequently seem supercial and incomplete (Cohen 1997). Although probably recording will not be encountered with a lot of positive expectations in learning the ‘art of physiotherapy’, there are various reasons why physiotherapists should consider the recording of the sessions they shape:
• Records serve as a mnemonic for the physiotherapist of what has been done, thought and planned • Systematic recording serves clinical reasoning and learning processes: committing thoughts to paper forces therapists to think more precisely and accurately and to become aware of their own reasoning processes. It enhances re ection and monitoring decisions made and actions taken 565
AP P E N D IX 2
Re c o rding
• Committing the essence of examination and
•
•
• • •
•
•
•
treatment ndings to paper is a valuable learning experience in itself. It forces one to identify the things that are essential, and record them, and leave out the less important information Committing thoughts to paper, with systematic recording, helps to clear the mind as the information and impressions gained throughout are organized Recording of patient information, actions and planning steps support the development of clinical patterns in memory. Therefore recording may be an essential process in the development of experiential knowledge (H iggs & Titchen 1995, Nonaka & Takeuchi 1995) Ideally, the records should document the trail along which assessment and treatment are moving Comprehensive, systematic patient records may serve as a basis for clinical case studies Records may be a mnemonic for the patient as well. In some cases, the patient may have forgotten how the disorder has been improved immediately following a treatment. If for other reasons a few days later the symptoms recur, the patient may easily interpret the condition as unchanged. Examination of the record made immediately following the treatment may guide the physiotherapist as well as the patient in the reassessment of the patient’s condition over the whole period directly after the last session until the moment that symptoms increased again Records aid communication in team collaboration. If a colleague is absent from work, the physiotherapist may be able to continue with the initialized course of treatment, provided the records are such that they are understandable Recording for legal reasons – in many countries physiotherapists are enforced by law to store their patient records for a certain period of time. Furthermore, physiotherapy records may be used in litigation An increasing number of professional associations declare documentation as an integral part of the physiotherapy process (Ö PV 1998, WCPT 1999, H eerkens et al. 2003). 566
SOAP notes Recording of therapy sessions must include detailed information, yet must be brief and provide a simple overview. Within this concept use has been made of the so-called ‘SOAP’ notes (Weed 1964, Kirk 1988). The acronym SOAP refers to the various parts of the assessment process: 1. 2. 3. 4.
Collection of subjective information Collection of objective information Performing an assessment Develop and formulate a plan.
It is not mandatory to follow the guidelines and abbreviations as set out in this book; however, some method must be determined to suit the patient’s comments and the therapist’s pattern of thinking. The basic elements of the SOAP mnemonic may serve as a useful format to follow all the steps of the therapeutic process in a brief and comprehensive way. It has been argued that the term ‘objective’ in the SOAP notes is somewhat awkward, due to the fact that the physiotherapist values the subjective experience of the patient while performing the test movements. Furthermore, it is argued that the physiotherapist as the ‘measuring instrument’ will give attention to those aspects of a test which seem most relevant at the time, and thus true objectivity in test procedures may not exist (G rieve 1988). It has therefore been decided to replace the term ‘objective examination’ with ‘physical examination’ (P/ E). There has been criticism that SOAP notes within problem oriented medical records (PO MR) would con ne the physiotherapist to focusing merely on biomedical data (French 1991); however, if the physiotherapist pays attention to key words and speci c key phrases of the patient which are indicative of the individual illness experience, they may be recorded in parentheses and integrated in the documentation, thereby incorporating elements of the individual illness experience into the records. At all times patient records should include the ndings as well as the steps in planning –a trail is laid of what is done and what is thought. Recording encompasses ideally:
• Information on examination and assessment procedures • Treatment interventions and results (reassessments)
S o m e re m a rks w ith re g a rd s to re c o rd in g
• Planning steps and hypotheses formulated • Important key words or phrases of the patient.
Box A2.1 Use of asterisks
As te ris ks During the subjective examination the patient may state certain facts related to the disability which may prove to be valuable parameters for reassessment procedures. These should be highlighted in the records immediately, and an ‘asterisk’ sign may be used. Although the use of asterisks is not mandatory, it may speed up the whole process. They are time savers, reminders and indicators of highly important facts for the particular person. Identifying these main assessment markers with a large, obvious asterisk not only enforces a commitment but also makes reassessment procedures quicker, easier, more complete and therefore more valuable. Using asterisks is just as valuable for the physical examination parameters as it is for the subjective examination. Similarly, making use of the asterisks progressively during the physical examination rather than after is recommended. The same applies to each subsequent session. At times it seems that the term ‘asterisk’ has become jargon; however, it is not meant in such a way. People teaching and working with this concept may frequently use the term ‘subjective and physical examination asterisks’. Mostly this refers to information of subjective and physical examination parameters which will be reassessed at regular intervals over the whole therapeutic process in order to monitor progress in rehabilitation and the effects of treatment (Box. A2.1).
Co nditio ns Some people may prefer other ways of recording. H owever, regardless the method of recording, some conditions need to be ful lled. Patient records need to be:
• • • • • •
O rganized Clear Comprehensive Simple to (re)read Written concisely, in telegraphese H omogenous, consequent.
As teris ks are an invaluable aid in as s es s ment procedures . The us e of an as teris k in recording highlights the following as pects : • Primary s ymptoms or activity limitations • Signs that reproduce a patient’s s ymptoms • Other important comparable s igns that will be followed up in reas s es s ment procedures • Other information that is important • Key is s ues that need to be followed up • ‘As teris k as you go along’ indicates that it is important to immediately highlight relevant ndings once they have been obtained rather than in retros pect. If the ndings have been recorded s traight away it will in uence the phys iotherapis t in the further procedures of examination and as s es s ment.
So me re marks with re g ards to re c o rding It is important to record related information even when the ndings indicate normality. By their having been recorded, reference at a later date shows that the particular questions have been asked or physical examination tests have been carried out. Recording normal ndings on a ‘record sheet’ is a quick and simple procedure. For example, if a patient has pain in the shoulder area and the therapist has examined the acromioclavicular joint comprehensively and found it to have normal painless movements, all that might be recorded is: AC The point is, it must be recorded. There is much more to be recorded from an initial consultation than for subsequent sessions. H owever, the same detail is required and so the same details and abbreviations can be used. People have likes and dislikes about these symbols – this does not matter, provided the criteria for comprehensive recording are met. Q uestionnaires as well as ‘cheat sheets’ as they are often termed, have advantages and disadvantages. The primary considerations are that they should not be regimented and they should not be detailed. A cheat sheet that has a list of questions requiring ticks and crosses, should not be used. They are in exible and destroy independent thinking on 567
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the part of the examiner, and they completely obliterate any chance of following the patient’s line of thought or the pursuit of hypotheses in greater detail.
• Reference to such a body chart provides a quick •
Re c o rding o f s ubje c tive e xaminatio n nding s With each patient there are many questions and answers that need to be entered in the recording, even if it is only to show that the question, which was important, has in fact been posed and answered. It is a safe procedure to utilize the patient’s words during the recording of subjective examination ndings. For example, if a patient complains of a pulling in the arm while lifting the arm above the head, this needs to be recorded as the patient said it, rather than the physiotherapist’s language of ‘symptoms or pain with exion’, as this may immediately narrow down the physiotherapist’s thinking. Key words and phrases indicative of the personal illness experience may be put in quotation marks. It has been emphasized that such key words and phrases may be essential information to the shaping of the therapeutic process, hence they have to be recorded accordingly. O rganization of the information in the main categories of the subjective examination is essential to keep an overview over the process of subjective examination. While asking questions regarding the ‘main problem’, it is possible that the patient gives information on history mingled with, for example, bits of symptomatic behaviour. In such cases it is relevant to leave suf cient space on the paper to organize and record the information under sections ‘history’ or ‘behaviour’ rather than writing down every bit of information in a chronological manner. This will help the physiotherapist to keep an overview over the whole process of subjective examination, even if the communication technique of ‘paralleling’ has been chosen.
Body chart • Frequently, after establishment of the patient’s main problem and receiving a more general statement about the perceived disability, the area, depth and nature, behaviour and chronology of the symptoms are clari ed and recorded on a ‘body chart’ (Fig. A2.1). 568
• •
•
•
and clear reminder of the patient’s symptoms and main problem. A well-drawn body chart helps to generate hypotheses on the sources of the movement dysfunction or symptoms as well as on the neurophysiological pain mechanisms. Additionally, rst hypotheses with regard to precautions and contraindications may be made. In principle, the body chart is drawn by the physiotherapist to facilitate recording and memory. O ccasionally, in patients with chronic pain states, the body chart may be drawn by the patient. If different colours are used, as a metaphor for the pain experience they may become a guide in reassessment procedures. If the information on a body chart is recorded consistently at the same place all the time, self-monitoring mechanisms are more easily activated. If the physiotherapist forgets to ask certain questions, this may be noticed more easily when re-reading the information. The use of Arabic numerals in circles for the different symptom areas simpli es later recording: if there is a need to refer to the symptom areas, the numerals can be used rather than lengthy descriptions of the symptom areas.
Clinical tip Always record the same information on the same spot of the body chart. This enhances self-monitoring – on re-reading the information it will be easier to discern if certain details are missing.
Behaviour of s ymptoms and activities The information on the ‘behaviour of symptoms’ is essential to the expression of many hypotheses. Furthermore, the information usually serves in reassessment procedures of subsequent sessions. Therefore the information needs to be recorded in suf cient detail. If activities or positions are found which aggravate the patient’s symptoms, this has to be recorded
Re c o rd in g o s u b je c tive e xa m in a tio n f n d in g s
1 Stabs I, D 3 Pulls stiff I, D 1a Pulls I, D
Pulls 2 I, D
1 1a Always together 2 if 1 ++ 3 No relation
Fig ure A2.1 • Example of a body chart.
meticulously. H owever, any easing factors also need to be written down straight away, on the same line as the activity which provokes the symptoms. This may sound pedantic to some; however, it will give the physiotherapist an immediate overview as to which activities and positions the patient has developed as useful coping strategies and with which ones the patient may need some help. Some examples are: ↑ G ardening, pulling weeds, in squat * position; after 10′ P1 , after 20′ 1 ↓ G ets up, walks around (few steps, shuttles leg): ↓ 100% immed. May continue gardening. ↑ Putting on socks, in standing – activity * possible as usual ↓ ↓ 100% immed. as soon as leg is put down.
*
↑ Lying in bed – prone, right leg pulled up. Wakes up c. 03:00 1 ↓ Does not know how to ease. G ets up, walks c. 20′ ‘acceptable’
His tory At times it may be dif cult to keep an overview of all the information regarding the history of a patient’s problem and to monitor if all the relevant data have been obtained. This may happen particularly in those circumstances where there have been more episodes and the problem has been recurrent for many years. Although not mandatory, the physiotherapist may draw a line indicative of the course of time to keep an overview of both the current and previous history (Figs A2.2, A2.3). 569
AP P E N D IX 2
Re c o rding
Current Hx
Since when
Details on onset of symptoms
Progression since onset
Now: onset
Since 4 weeks
Judo: fall on side – little pulling, groin Could continue judo training
Same. Does not bother DLA much No medic., or other Rx Went to GP because ‘annoying’ GP PT
Same
Sy. 1 little bit day 1, over c. 7 days difficulties with gardening, judo, stiffness a.m.
Fig ure A2.2 • Time line: current history.
Re c o rding o f phys ic al e xaminatio n nding s Physical examination ndings need to be recorded in suf cient detail and systematically in order to allow for quick referencing during subsequent reassessment procedures. Making use of symbols helps speed up the process and enhances quick referencing (Table A2.1).
Ac tive mo ve me nts When recording the range and quality of movement and the symptomatic response to that movement, one should develop a pattern of recording and stick to it. By doing so, more facts can be remembered, while at the same time leaving the therapist’s mental processes more time to take in other details. Active movement ndings can be recorded as follows: Sup
,
IV + +
This example means supination (sup) has a normal range and quality of movement (the rst tick, ) and has no abnormal pain response when overpressure is applied (the second tick, ). It is suggested relating the rst tick ( ) to movement responses such as range and quality of movement and the second tick ( ) to symptom responses which occur during the test movement. It may be indicated with a grading of IV−, IV++ or IV+ how rm the overpressure has been. This is particularly relevant in those cases where the physiotherapist wants to test the movements with a certain amount of overpressure; however, factors in the ‘nature of the disorder’ may limit the physiotherapist in applying maximum overpressure. A movement cannot be classed (or recorded) as normal unless the range is pain free both actively and passively. Further overpressure applied at the limit of the available range should not cause pain other than normal responses. Abnormal ndings may be recorded as follows: *Ab 170 °, Dev. Ventr. 120 −170 °, Corr. Dev. 130 °, 11
act . EO R
Previous Hx
1995
2000
2002
2003
2004
- after marathon - after c. 1 week gone
as 1995
- after judo championship - gone after 1 week
as 2002
- after judo training (current Hx)
Between episodes: no symptoms, no disabilities Current episode: does not disappear with little stretching exercises as in other episodes
Fig ure A2.3 • Time line: previous history. 5 70
Ac tive m o ve m e n ts
Table A2.1 Recording symbols
Peripheral joints
Spine
F E
Flexion Extension
Central posteroanterior pressure (PAs) with a L inclination
Ab Ad
Abduction Adduction
Central anteroposterior pressures (APs)
Medial rotation
Unilateral PAs on L inclination
Lateral rotation
Unilateral APs on the L
HF HE
Horizontal f exion Horizontal extension
Transverse movement towards L
HBB
Hand-behind-back
Rotation towards L
Inv
Inversion
Lateral f exion towards L
Ev DF
Eversion Dorsif exion
Longitudinal movement (state cephalad or caudad)
PF
Plantarf exion
Unilateral PAs at angle o R 2nd rib
Sup Pron
Supination Pronation
Further laterally on R on 2nd rib
El
Elevation
Unilateral APs on R
De
Depression
CT &
Cervical traction in f exion
Protr
Protraction
CT &
Cervical traction in neutral (sitting)
Retr
Retraction
IVCT &
Sitting
Med Lat
Medial Lateral
IVCT &
Lying
OP
Overpressure
PPIVM
Passive physiological intervertebral movements
IVCT & 10 3/0 15
Intermittent variable cervical traction in some degree o neck f exion, the strength o pull being 10 kg with a 3-second hold period, no rest period, or a treatment time lasting 15 minutes
PAIVM
Passive accessory intervertebral movements
ULNT
Upper limb neural tests
LLNT
Lower limb neural tests
LT
Lumbar traction
Q
Quadrant
LT 30/15
Lumbar traction, the strength o pull being 30 kg or a treatment time o 15 minutes
Lock
Locking position
with a medial
5 71
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Table A2.1 Recording symbols—cont’d
Peripheral joints
Spine
F/Ab F/Ad
Flexion abduction Flexion adduction
LT crk 15/5
Lumbar traction with hips and knees f exed: 15 kg or 5 minutes
E/Ab
Extension abduction
IVLT 50 0/0 10
Intermittent variable lumbar traction, the strength o pull being 50 kg, with no hold period and no rest period, or a treatment time lasting 10 minutes
E/Ad
Extension adduction
Distr
Distraction Posteroranterior movement Anteroposterior movement Transverse movement in the direction indicated Gliding adjacent joint sur aces Compression Longitudinal movement:
Ceph
Cephalad
Caud
Caudad
Longitudinal movement is the direction o movement o a joint in line with the longitudinal axis o the body in its anatomical position. When that same movement is per ormed in any other position than the anatomical position, that movement o the joint is still called longitudinal movement even though it is not now in line with the longitudinal axis o the body Spinal data reproduced by kind permission from Maitland, G. D., Hengeveld, E., Banks, K. & English, K. 2001. Maitland’s Vertebral Manipulation, 6th edn. Oxford: Butterworth-Heinemann
This indicates that the range of abduction has been 170°, with a deviation of the movement between 120° and 170° of abduction; symptom reproduction occurred at the active end of range without application of overpressure. With correction of the deviation in the movement, the range decreased until 130° of abduction and the pain was clearly increased. *H ip F 130°, loc P groin IV −,
IV +
This example shows that the overall range of hip exion was 130°, without any deviations in the quality of the movement; local symptoms were produced with a light overpressure (‘IV−’), symptom 5 72
reproduction occurred with stronger overpressure (‘IV+’).
Pas s ive mo ve me nts With passive movement the behaviour of pain, resistance and motor responses (spasm) is monitored. The physiotherapist is particularly interested in how these components behave and relate to each other. This is a very detailed examination procedure and may be considered as a part of the ‘art of manipulative physiotherapy’. Most simply, but
Re c o rd in g o tre a tm e n t in te rve n tio n s R2 (IV++)
• The position of the patient • The position of the joint • Selected treatment technique(s), including
D
⁄2
⁄2
1
1
—
i
r
r
i
t
a
b
i
l
i
t
y
—
n
a
t
u
r
e
C
S
e
v
e
r
i
t
y
P'
• • • •
A
⁄4
1
L3⁄4 R1 1⁄2 P1 (locally hamstring-area)
B
Range
inclinations of the movements G rade(s) of the technique Rhythm in which the technique was performed Duration (in number of repetitions or time units) Symptomatic responses and the patient’s reactions while the intervention is being performed (‘assessment during treatment’ – see Chapter 1) Reassessment immediately following the technique (it is usually helpful to make comparisons or statements as to which parameters have improved and which ones have stayed unchanged).
Fig ure A2.4 • Movement diagram.
•
not mandatory, would be the drawing of a movement diagram, as delineated in Appendices 1–3 of Volume 1. O therwise abnormal ndings regarding the behaviour of P 1 and P’, R1 and R2, including their relationship, may be recorded verbally. If certain passive movements are classed as normal, the same method ( ), )) as with active movements may be used. H owever, if relevant abnormal ndings are present, this method is not suf ciently comprehensive. Example:
It is essential not only to record the treatment by passive movement in detail but also active procedures, exercises or physical applications (e.g. ultrasound requires the same depth of recording). Treatment is followed by a reassessment in which patients are asked to make a comparison of any changes of symptoms or in their sense of wellbeing resulting from the technique. This is then followed by a reassessment of the affected physical examination tests. Ideally, the records of the physical examination ndings include a brief appraisal of the results in comparison with the assessment just before the application of the treatment technique. Finally, at the end of a treatment session, the clinician should commit to paper thoughts on how treatment needs to be modi ed at the next session. Such an analysis not only forces the clinician to re ect on clinical reasoning processes, but also stimulates memory of the last treatment session.
SLR R : R1: 50 °, L 5 R 2 70 °; P1 pulling hamstr . c. 55 °, P ′ only little ( 3 / 10). This example indicates that the physiotherapist rst felt an increase in resistance with c. 50° of SLR, the movement was limited by resistance at c. 70° of SLR, only a little pulling sensation was provoked in the hamstrings area. Figure A2.4 illustrates the associated movement diagram.
Exa mp le s :
Re c o rding o f tre atme nt inte rve ntio ns Before performing a treatment technique, the planning and the reasoning for its selection should be recorded. Next, the treatment and its effect should be written down. This needs to include suf cient details in order to be able to refer back at later stages when making retrospective assessments. The treatment record for a passive mobilization technique should contain:
• Passive movement: Rx G / H , Supine In: 150° F (before P1) Do: , IV− to IV Smooth rhythm, rel. quick Totally c. 6′ ‘Comfortable’; after 4′ R1 to L, especially with After c. 6′ no further changes in P or R
C/ O : P/ E:
Plan:
‘same’ F 160°, IV++ (‘feels much freer, I can move higher’) H BB: range & P ISQ repeat same Rx; if H BB remains ISQ , do acc. mvt in EO R H BB 5 73
AP P E N D IX 2
Re c o rding
Othe r forms of tre a tme nt: • Exercises
C/ O :
In sitting: do F/ Ad hip R and L 5×, c. 10″, until slight pulling buttock ‘Comfortable’
P/ E:
‘lighter than before to stand’ Lx F: 2 cm, , act EO R
• U ltrasound
H ip F: 130°, IV+ Plan: do ex. at/ work; at least 3×/ day A P buttock starts. 1–2 series; 5×/ 30″ each leg C/ O : ‘not tender now’
Sitting, knee extended
P/ E:
Rx: US 3 MH z, large head; 1 : 2 int. 1.0 W/ cm 2 ; 3′; on tender spot, medially knee No pain
E/ AB:
Squat: full range, ,
, IV+
(It is frequently useful to compare the results and to mark which elements may have improved following the intervention)
Info rmatio n, ins truc tio ns , e xe rc is e s , warning at the e nd o f a s e s s io n Any information or instruction given during the treatment, any exercise that the patient should perform as a self-management strategy needs to be recorded as well. At the beginning of a treatment series it is often important to warn the patient diplomatically for possible exacerbations. This also needs to be recorded.
Exa mp le • Warned about possible increase; however, if spot gets smaller, may be a good sign. • Should observe and compare: – mornings getting out of bed – changes in stiffness? – working in garden – anything different from before? – nights – anything changing in sleep pattern? – effect of exercise, if pain occurs? • Instruction (e.g. remembers anything particular about fall during judo?). 5 74
Re c o rding o f fo llo w-up s e s s io ns When recording follow-up sessions, the rst words must include a quotation of the patient’s opinion of the effect of the previous treatment. This quotation must be worded in such a way that it is a ‘comparison’ rather than just a ‘statement of fact’. The subjective reassessment is then completed in which the physiotherapist clari es those activities that serve as parameters and have been highlighted with an asterisk in the records of previous sessions. Following the subjective reassessment the record includes the physical examination tests which are being reassessed. These too are recorded as comparisons with the previous ndings. Changes in the physical examination ndings will hopefully agree with the ndings of the subjective assessment, so reinforcing each other. This will then make the total assessment more reliable. Also during reassessment of physical examination tests it may be necessary to record key words and phrases; in the rehabilitation of, for example, shoulder problems it may be a good sign if the patient makes the spontaneous remark: ‘the arm is mine again’. The following pattern may be used in recording follow-up sessions: • Date, time of the day, R× 3, D8 (indicating third session on eighth day since the initial consultation) • C/ O spontaneous information: ‘better’, ‘felt lighter than before’ • C/ O follow-up of subjective parameter: putting on socks today cf. yesterday: no pain (5 unusual! First time in 3 weeks!) • PP • P/ E: reassessment of physical examination parameter (including statements of comparison with after/ before the previous treatment) • P/ E: additional tests as planned • Plan: e.g. stick to plan as stated after R× 2 • R× 3a (as above) … • R× 3b (as above) … • Plan
Re tro s pe c tive as s e s s me nt The record of retrospective assessment has to stand out from other parts of the treatment so that
C o n c lu s io n
the information can be easily traced on reviewing progress in later sessions. This is particularly important when a patient has an extensive disorder and considerable treatment. To be practical, time must be a consideration, but not at the expense of detail and accuracy. Especially within retrospective assessment, in the written record three requirements should be respected: 1. To stand out from other data (to be highlighted so that it is readily seen on checking back through the record). 2. To state with what time frame the comparison is made (e.g. R × 5 cf. R × 1). 3. To emphasize spontaneous information. Retrospective assessments should include the following information and comparisons:
• G eneral wellbeing compared with, for example, • • • • • • •
•
four sessions ago Symptoms compared with, for example, four sessions ago (know indicators of change – see Chapter 5) Level of activities compared Effect of interventions so far (P/ E and passive movements) Effect of instructions, recommendations and exercises so far What has the patient learned so far – what was particularly relevant to the patient? Comparison of all the relevant physical examination parameters compared with, for example, four sessions ago Which interventions brought which results? (certain physical examination ndings may improve more with some interventions than with others) G oals for the following phases of treatment (process of collaborative goal setting: rede nition or con rmation of agreed goals to treatment, interventions and the parameters to measure if the objectives are being achieved).
Writte n re c o rds by the patie nt There are times when it is necessary for a patient to write a running commentary of the behaviour of the symptoms. For example, a patient may be a poor
historian in which case he may be asked to write down how he feels immediately following treatment, how he feels that night and how he feels on rst getting out of bed the next morning. Some people may feel this is encouraging a patient to become overly focussed on his symptoms. H owever, if the patient is asked not only to record how he feels, but also the level of activities, medication intake and possible self-management interventions, such a record may become a highly valuable teaching instrument which aids both the patient and the physiotherapist. There are many different types of pre-printed form that can be used. H owever, it is essential that the forms leave space for information regarding: • Symptoms • Activities before and during the increase of symptoms • Activities throughout the day/ week • Employment of self-management strategies to in uence wellbeing, including the effects of the interventions. When a written record by the patient is used, it should be handled by the manipulative physiotherapist in a particular sequence: 1. O n receiving it from the patient, it should be laid down. 2. The patient should be asked to give a general impression of the effect of the last treatment. 3. The subjective assessment of the effect of the last treatment should be taken through to its conclusion. 4. The written record can then be assessed and any discrepancies clari ed.
Co nc lus io n Although recording of examination ndings, treatment interventions and results, and regular planning, may not be the most interesting part of learning, it is an essential element of the quality of the overall therapeutic process. It monitors the physiotherapist throughout the process and allows quick adaptation of interventions, if needed. When recording is accurate and succinct, and can be correctly interpreted by another person reading it, it is an invaluable self-teacher and may support physiotherapists on their path to expertise and maintaining this. 5 75
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References Cohen L: Documentation. In Wittink Verslaglegging, Amersfoort, 2003, H , Michel TH , editors: Chronic Pain KNG F. M anagement for Physical Therapists, H iggs J, Titchen A: The nature, Boston, 1997, Butterworthgeneration and veri cation of H einemann. knowledge. Physiotherapy, 81: French S: Setting a record straight, 521–530, 1995. Therapy Weekly 1:11, 1991. Kirk D: Problem O rientated M edical G rieve G P: Critical examination and Records: G uidelines for Therapists, the SOAP mnemonic, Physiotherapy London, 1988, Kings Fund 74:97, 1988. Centre. H eerkens YF, Lakerveld-H ey K, Nonaka I, Takeuchi H : The KnowledgeVerhoeven ALJ, et al: KN G F Creating C ompany, New York, – Richtlijn Fysiotherapeutische 1995, O xford University Press.
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Ö PV: Broschüre Berufsbild Physiotherapeut, Vienna, 1998, Ö sterreichischer PhysiotherapieVerband. WCPT: Description of Physical Therapy, London, 1999, World Confederation of Physical Therapy. Weed L: Medical records, medical education and patient care, Ir J M ed Sci 6:271–282, 1964.
Inde x
Page numbers ollowed by ‘ ’ indicate f gures, ‘t’ indicate tables, and ‘b’ indicate boxes.
A abbreviation symbols, 571t–572t abduction hip, 431–432, 431 extension/ abduction, 432–433 in supine, 400, 400 interphalangeal joints, 364–365, 364 knee, 469 , 493 with extension, 489–490 with exion, 490–491 metacarpophalangeal joints, 364–365, 364 see also exion abduction (valgus) stress test, 476–477 abductor pollicis longus, 329 accessory movements oot/ ankle ore oot, 544–546 hind oot, 537–544 hip, 380, 414–417 knee, 493–498, 498 superior tibiof bular joint, 502–504 temporomandibular joint, 116–127, 116 see also individual areas, or detail acetabular labrum, tears, 440t–441t Achilles tendinopathy, 516, 519 acromioclavicular joint, 155, 230b–231b physical examination, 230b–231b squeeze test, 210t–212t acromioclavicular lesions, 210t–212t clinical eatures, 210t–212t onset and aetiology, 210t–212t pathology, 210t–212t physiotherapy implications, 210t–212t
acromioclavicular osteoarthritis, 210t–212t acromiohumeral joint, 229b–230b physical examination, 229b–230b active unctional movements, 105, 105 , 272–275, 325–326, 466 active movement tests craniomandibular disorders, 106 oot/ ankle, 528 hand/ wrist, 333–337 hip, 394–395, 466–468 knee, 466–467 record keeping, 570–572 see also specif c tests activity, 67 activity levels, 79–80, 454, 558 activity limitations, 4t, 5, 67 knee pain, 462–463 adduction hip, 411–413, 412 –415 , 416 exion/ adduction, 411–414, 416, 425–426, 425 in supine, 400–401, 401 interphalangeal joints, 364–365, 364 knee, 469 –470 , 493 with extension, 489–490 with exion, 490–491 metacarpophalangeal joints, 364–365, 364 see also exion adduction (varus) stress test, 477 adductor brevis, 382b tests, 405–406, 405 adductor longus, 405–406, 405 adductor magnus, 382b tests, 405–406, 405 adductor tests, 405–406, 405 , 409–410, 409 adhesive capsulitis, 148t algorithms, 14 , 122, 233 , 561–562 allodynia, 6, 11, 278 altered nervous system processing models (ANSPM), 81
American Physical Therapy Association (APTA), physiotherapy diagnosis, 215–216 analytical assessment, 33–34, 33 clinical standards, 47b–49b anatomy elbow, 262–263, 282 oot/ ankle, 512–514, 513 knee, 451–452 temporomandibular joint, 89–90, 90 ankle see oot/ ankle anterior capsular insu f ciency see anterior drawer test anterior cruciate ligament rupture, 462 anterior drawer test, 475 anterior glide o hip excessive, 416, 416 restricted, 416 anterior knee pain, 457, 459t–460t anterior pelvic tilt, 465 anterior release test, 156 anteroposterior movement cervical spine, 178 craniomandibular complex, 119–120 distal tibiof bular joint, 539, 539 oot/ ankle IV-ray, 545–546, 545 medial cunei orm bone, 545, 545 head o radius, 299, 302 hip, 421–422, 422 intercarpal joint, 357–358, 357 knee, 495–497, 496 mandible, 119–120 midtarsal joint, 544, 544 radiocarpal joint, 352, 352 radioulnar joint, 339–343, 342 subtalar joint, 542, 542 , 548, 548 superior tibiof bular joint, 502–503 talocrural joint, 540–541, 540 , 546–548, 546 , 548 anteversion, emoral, 465–466 Appley’s grind test, 477 application o orces see specif c regions 5 77
Inde x apprehension test, 156 , 479 APTA see Americal Physical Therapy Association area o symptoms craniomandibular disorders, 99t oot/ ankle pain, 521 hand/ wrist pain, 329–330, 329 hip pain, 388–389, 388 knee pain, 462 see also body charts arms dynamic control, 277–278 neurodynamic testing, 278–282 upper limb neural provocation test (ULNPT), 179 arthritis osteoarthritis see osteoarthritis rheumatoid, 313 arthroplasty, shoulder, 216 articular cartilage, 452, 454, 487 ascending/ descending steps test, 396 assessment, 2, 8, 30–46, 73 analytical, 33–34, 33 during treatment procedures, 40 ESP role, 177b–179b f nal, 41, 42b orms o , 34–41, 35 initial, 34–35 objectives, 35 outcome measures, 30–33 retrospective, 41, 41b see also reassessment asterisks, in record keeping, 567, 567b asymmetry, 112, 262 athlete’s groin, 377t–378t, 439t–440t treatment, 386t–387t attentive listening, 75 attributes, 47 autonomic nervous system, in pain perception, 79t–80t autonomous practice, 47–50 privileges o , 49–50 axes o movement, 514 axillary nerve entrapment, 172t–174t axonmechanosensitivity, 278–279
B balance board, 551, 551 Bankart lesions, 194t–196t barriers to compliance, 559 bear-hug test, 151 behaviour o symptoms, 8, 568–569 craniomandibular disorders, 96–99 elbow pain, 264–265, 264t oot/ ankle pain, 522 hand/ wrist pain, 330 hip pain, 389 knee pain, 462–463 record keeping, 568–569 see also specif c conditions behavioural parameters, 39b belly-press test, 151, 152 , 223t–226t Bennett angle, 109 Bennett shi t, 109 Bennett’s lesion, 161, 167–168
5 78
best evidence, 68, 72 best practice, 13 bias, 149–151 biceps load tests, 154 , 223t–226t bicipital tendinosus, 377t–378t bilaminar zone, 90 bio-psychosocial paradigm, 43, 43 , 50–54, 73–78 and healthy living, 52 , 54 in manipulative physiotherapy, 52–53, 53b movement continuum theory see movement continuum theory phenomenological perspective, 75–78, 78 role o , 75–78 bio-psychosocial practice, 2–5, 52 biomechanical paradigms, 83 biomedical paradigm, 52, 53b, 72–78 role o , 74–75 blocked joints, 380–381 bodily awareness, 77 body adapting, 7–9 in orming, 7–9, 7b structures, 67 body charts, 8, 568, 569 craniomandibular disorders, 95–96, 95 , 133 elbow, 263–264, 318 hand/ wrist, 329 , 373 hip, 388 , 444 knee, 462, 505 shoulder, 178 , 183 , 187 , 234 , 237 , 240 , 243 , 246 , 249 see also area o symptoms Bone and Joint Decade, 450–451 bones oot, 513 hand, 327, 327 –328 brachial neuritis, 172t–174t brachial plexus tension tests, 177 ‘brick wall’ model, 9–10, 10 , 10t, 72 ICF/ ICD and, 53–54, 54t shoulder pain, 220–222, 221 brie appraisal, 26b, 37b craniomandibular, 103b, 105–112 elbow, 268–272 hand/ wrist, 331–332, 334b, 336, 338, 373 hip, 391, 394 knee, 466 shoulder complex, 184, 227–233 bruxism, 89, 96, 100 bulge sign, 474 bursitis ischial, 377t–378t prepatellar, 474 trochanteric, 377t–378t, 441t–442t
C C1 (cervical spine) see cervical spine, C1 area calcif c tendonitis, 148t, 198t associated conditions, 198
clinical eatures, 162 diagnosis, 198 management, 198 onset and aetiology, 198 pathology, 198 physiotherapy implications, 198 see also entries under rotator cu capsulitis, 148t care pathways, 13 carpal bones, 327, 327 –328 carpal tunnel syndrome, 326, 329 carpometacarpal joints extension, 360–361, 360 exion, 360–361, 360 mobilization, 350 physical examination, 334b, 336b o thumb, 336b case studies craniomandibular disorders, 132b–135b elbow, 318b–320b hand/ wrist, 372b–374b hip, 443b–447b knee, 504b–508b shoulder, 162b, 177b–179b, 183b–184b, 186b–188b, 232–233 catastrophizing, 182 categorization o hypotheses, 523–525 caudad movement craniomandibular complex, 117–118, 118 hand/ wrist, 344, 344 , 361–363, 362 , 366–367, 367 hip, 419–421, 420 knee, 493–494 central nervous system modulation, 79t–80t central sensitization, 261–262 centric relation splint, 102 cephalad movement craniomandibular, 120–121 craniomandibular complex, 120–121 hand/ wrist, 344, 344 , 358–359, 358 , 366–367, 367 hip, 422–423, 423 knee, 493–494 cervical compression test, 177 cervical myelopathy, 174t–175t cervical radiculopathy, 174t–175t cervical side glide, 241 cervical slump test, 113 cervical spine active tests, 113 C1 area, occiput-C1 longitudinal cephalad technique, 123–124, 124 extension see extension, cervical spine mobilization, anteroposterior accessory, 178 rotation see rotation, cervical spine and shoulder pain, 172–177, 174t–175t
In d e x cervicobrachial pain syndrome, 174t–175t cervicothoracic spine, 179, 236 change indicators o , 39, 39b phases o , 83 stages o change model, 83 Chartered Society o Physiotherapy, 49–50, 143 chondrocytes, 487 chronic pain elbow, 317, 317b oot/ ankle, 517–518 hand/ wrist, 371b circumduction hip, 415 interphalangeal joints, 369, 369 –370 metacarpophalangeal, 369, 369 –370 client-centred care, 70, 75 see also patient-centred practice Clinical Assessment and Treatment Services (CATS), 182–186 clinical groupings, 30, 30 clinical practice pillars o , 2–3 standards o , 47b–49b clinical practice ramework, 1–3, 3 healthy living, 4 clinical prediction rules, 217–219 clinical reasoning, 2, 9–13 best practice, 13 ‘brick wall’ see ‘brick wall’ model complex processes, 80–81 elbow disorders, 314t–315t and evidence-based practice, 71–72 expert clinicians, 11–13 knee pain, 461 patient-centred, 10–13 role o , 13, 14 strategies, 27, 27b treatment selection/ progression, 11 clinical reasoning orm, 15b–19b clinical standards physical examination, 47b–49b reassessment, documentation and analysis, 47b–49b subjective examination, 47b–49b treatment, 47b–49b clinical syndromes elbow, 313–318 oot/ ankle, 516–518 hip, 377t–378t, 385t–387t, 437t–443t knee, 453–461 see also case studies clinical tests see tests/ testing cognition, 9, 44 cognitive processes and injury, 517 cognitive-behavioural paradigms, 82–83 phases o change, 83 cognitive-behavioural therapy, 34, 40 sel -management, 559–560, 559 coherence, sense o , 76 collaborative reasoning, 9
collagen f bres, 166t–167t combined movements o oot and ankle, 546–549 communal peroneal nerve, palpation, 474 communication during examination, 20 errors, 6 nonverbal, 6–7 patient-centred, 6–7 patient-therapist, 75 competencies, 46–50 IFO MPT, 2, 46–47 O MT, 46–47, 46b standards o clinical practice, 47b–49b complex regional pain syndrome (CRPS), 326 compliance, 559 barriers to, 559 enhancement, 83, 561–563 coping strategies, 562 integration o exercises into daily li e, 562–563 long-term, 561 short-term, 561 component analysis with passive movements, 26b comprehensibility, 76 compression oot/ ankle distal tibiof bular joint, 539–540, 539 hind oot, 547, 547 talocrural joint, 541, 541 hand/ wrist humeroulnar joint, 274 radiohumeral joint, 274 –275 radioulnar joint, 276 , 343, 343 hip, 423–425, 424 knee, 485b–487b, 486 temporomandibular joint, 125, 125 compression tests active, 210t–212t cervical, 177 elbow, 265 O ’Brien’s, 154 , 157, 223t–226t compressive neuropathy, 278–279 consultation uture sessions, 37b initial, 35–38, 36b see also assessment; examination continuum o movement see movement continuum theory contraindications, 525 contributing actors, 5, 11, 44 convex-concave rule, 83 coping strategies, 562 core stability, 466 costal joints, 233b costovertebral joints, 174t–175t Craig’s test, 402 craniomandibular complex, 88–141 accessory movements, 116–127, 116
extraorally applied, 116–117 intraorally applied, 117–121, 117 –118 active movement, 106 body charts, 95–96, 95 brie appraisal, 105–112 mouth closing (elevation), 109, 109 mouth opening (depression), 106–108, 134 protraction, 109, 110 retraction, 109–112, 110 –112 sitting, 105–106, 106 case study, 132b–135b causes o dys unction, 91–94, 92 contributing actors to dys unction, 101 history o symptoms, 99–102 events, 100 gradual onset, 101 spontaneous onset, 100 trauma, 99–100 hormonal actors, 89 isometric tests, 112–113 active tests o cervical spine, 113 supine lying, 112–113, 113 management, 127–132, 128t distraction therapy, 101 electromassage, 129 exercises, 131 , 132b–135b taping, 129 –130 medical screening questions, 101–102 neurodynamic tests, 113–114 cervical slump and occipital nerve major test, 113 acial nerve, right side, 114 mandibular nerve, right side, 113–114 neurological examination, 113 observation, 102–103 en ace, 102–103 intraoral, 115–116 in prof le, 103, 112 sitting, 102 standing, 102 palpation extraoral, 92 , 114–116 and intraoral observation, 115–116 stomatognathic muscles, 114–115 temporomandibular joint, 114 physical examination, 102–112, 103b unctional demonstration, 105, 105 present pain, 102 precautions, 113–114 subjective examination, 94–102 symptom behaviour, 96–99 symptom localization, 99t types o , 94–95 see also temporomandibular joint
5 79
Inde x cranium examination o , 122–124 occiput-C1 longitudinal cephalad, 123–124, 124 temporal bone, 124, 124 crank test, 155 , 223t–226t crepitus, 479 critical phases o therapeutic process, 34, 35 cubital tunnel syndrome, 279–280 current movement capacity, 50–51
D de Q uervain’s tenosynovitis, 329, 337 decision making, patient participation, 5–6 decompression o temporomandibular joint, 125, 125 deep gluteus maximus test, 404, 404 degenerative joint disease, 99t, 119, 210t–212t dental malocclusion, 115 dental occlusion, 88–90 centric, 89–90 aults in, 100 dermatomes, hand/ wrist, 338 diagnosis, 66–68, 73, 145 assessment see assessment ESP role, 145–146 ICF dimensions, 73, 74 medical, 144, 145 , 168 physiotherapy, 144–145, 145 problems, ‘brick wall’ see ‘brick wall’ model statistical concepts, 149t–150t see also clinical reasoning; physical examination; and specif c conditions diagnostic accuracy, 149–151, 149t–150t physical tests, 151 diagnostic labels, shoulder pain, 146–149, 147b, 148t, 180–181 ‘di erentiation by treatment’, 38 di erentiation, structural, 8 di erentiation tests elbow, 285 hip, 413, 414 knee, 466 Disabilities o Arm, Shoulder, and H and (DASH ) questionnaire, 265 disclusion, 88 distal tibiof bular (syndesmosis) joint accessory movements, 538 anteroposterior movement, 539, 539 compression, 539–540, 539 normal movements, 514 posteroanterior movement, 538–539, 538 distraction hand/ wrist, 276 knee, 499
580
subtalar joint, 542–543, 542 talocrural joint, 540–541, 541 , 548, 548 temporomandibular joint, 101, 126 distraction splint, 102 doctors expert clinicians, 11–13 medical diagnosis, 144, 145 re errals rom, 144 role o , 144–146 documentation clinical standards, 47b–49b treatment records, 61 see also record keeping dorsal scapular nerve entrapment, 172t–174t dorsi exion oot/ ankle, 530, 530 , 549–551, 550 subtalar joint, 546, 546 talocrural joint, 546–547, 546 dosage parameters, 58 double crush, 326 Duchenne sign, 394–395 Dupuytren’s contracture, 337 dysaesthesia, 521
E e usion, knee, 474 elbow, 261–323 anatomy, 262–263 joints, 282 biomechanics, 262–263 body charts, 263–264, 318 case study, 318b–320b clinical syndromes, 313–318 chronic minor pain, 317, 317b clinical reasoning, 314t–315t epicondylalgia, 29, 29 gol er’s elbow, 263 screening, 317, 317b sti ness, 316–317 tennis elbow, 261–263, 266, 275, 316 evidence-based practice, 266–268 extension see extension, elbow exion see exion, elbow MWM, 277 , 284–285, 301–309 neurodynamic mobilization, 312–313 cervical lateral glide, 312, 312 scaphoid IV and V, 312–313, 313 neurological examination, 285–286 palpation, 278, 279 nerve trunks, 286 see also individual nerves passive movement, 282–284, 282 –284 , 286–301, 317b physical examination elbow complex, 272–313, 317–318 elbow region, 268–272, 268b–269b unctional demonstration, 272–275
muscle isometric/ length testing, 278 neurological, 278–282 observation, 272 precautions and planning, 272 prone lying, 272 side lying, 272 sitting, 270–271 standing, 270 supine, 271–272 upper limb dynamic control, 277–278 see also tests, below pronation see pronation, elbow resisted exion, 223t–226t subjective examination, 263–266 history, 266 special questions, 266 symptom behaviour, 264–265, 264t supination see supination, elbow tests di erentiation, 285 i necessary, 275–277 isometric, 278 MWM, 277 , 284–285 neural di erentiation, 277 neurodynamic, 278–282 screening, 317, 317b trauma, 268 see also individual joints electromassage, masseter muscle relaxation, 129 electromyography, 457 emotional motor system, 92–93, 122 empathy, 75 empty can test, 153 , 223 end-o -range pain shoulder, 162b temporomandibular joint, 99t, 128t end-organ dys unction, 80–81 entrapment neuropathy, 326 environmental actors, 67 epicondylalgia, 29, 29 lateral see lateral epicondylalgia medial (gol er’s elbow), 263 epiphysiolysis o emoral head, 390 errors, communication, 6 ESPs see extended scope practitioners eversion, 393t, 431, 471–472, 514–515 evidence-based practice, 3, 50, 68–72 best evidence, 68, 72 and clinical reasoning, 71–72 def nition, 68 dilemmas and challenges, 68–71 elbow, 266–268 hip, 385, 385t–386t knee, 451–461 levels o evidence, 69t examination clinical reasoning, 2, 9–13 communication, 20 hypothetico-deductive reasoning, 11–12 pattern recognition, 74
In d e x prognosis, 5, 41–46, 74 see also physical examination; subjective examination exercises craniomandibular disorders, 131 , 132b–135b elbow, 267 oot/ ankle, 549–551 balance board, 551, 551 in dorsi exion, 549–551, 550 motor control, 551–555, 555 therapeutic, 549 integration into daily li e, 562–563 record keeping, 574 experiential knowledge, 67 expert clinicians, 11–13 expert opinion, 69t extended scope practitioners, 142–144 def nition, 143 diagnosis by, 145–146 role o , 143–144 assessment, 177b–179b practice and diagnosis, 168–169 extension cervical spine, 105 elbow, 273 , 276 , 286–288, 288 , 291–294, 292 –293 extension/ abduction, 288–290, 289 extension/ adduction, 286–288, 288 grade III (IV), 293 with lateral glide, 303, 305 with medial glide, 303–304, 305 with ulnar lateral tilt, 307–308, 309 with ulnar medial tilt, 308, 309 hand/ wrist carpometacarpal, 360–361, 360 intercarpal, 355 metacarpophalangeal/ interphalangeal, 363–364, 364 , 369, 369 –370 midcarpal, 348–349, 348 radiocarpal, 347–348, 347 wrist, 346–347, 347 hip in prone, 401, 401 in treatment, 432 knee, 467, 469 , 489–490 in supine, 467, 467 tibio emoral joint, 488–489, 488 extensor policis longus, 329, 329 external rotation lag sign, 152 , 223t–226t
F FABER test, 471 acial areas, representation o , 93 acial nerve, neurodynamic testing, 114 emoral anteversion, 465–466 emoral condyles, 451 emoral head, epithysiolysis o , 390
emoral nerve palpation, 473 testing, 471, 471 emoroacetabular cam impingement, 390 f ght or ight, 79t–80t f nal assessment, 41, 42b Finkelstein’s test, 337 f tness, 451 exion elbow, 273 –274 , 276 , 294–296, 294 exion/ abduction, 290–291, 291 exion/ adduction, 290, 290 grade II, 294 grade III and IV, 295 with lateral glide, 304–306, 307 with longitudinal caudad glide, 308, 309 with longitudinal movement caudad, 295–296, 295 –297 with medial glide, 306–307, 307 resisted, 223t–226t oot/ ankle dorsi exion, 530, 530 , 532–533, 533 , 535, 535 , 546–547, 546 plantar, 530, 530 , 532, 532 , 534, 534 , 549, 549 subtalar joint, 548, 548 hand/ wrist carpometacarpal, 360–361, 360 intercarpal, 356, 356 metacarpophalangeal/ interphalangeal, 363–364, 363 , 369, 369 –370 midcarpal, 346, 346 radiocarpal, 345–346, 345 wrist, 344–345, 345 hip, 411–413, 412 –415 , 416 in our-point kneeling, 398–399 in supine, 397–398, 398 knee, 467–468, 468 , 470 , 490–491 patello emoral joint, 501–502, 502 ollow-up, record keeping, 574 oot/ ankle, 512–557 accessory movements, 537–546 active movement tests, 528 anatomy, 512–514, 513 bones o oot, 513 clinical syndromes, 516–518 ankle instability, 516–517 chronic, 517–518 cognitive processes and injury, 517 plantar asciitis, 516 combined movements, 546–549 extension see extension, oot/ ankle exion see exion, oot/ ankle ore oot see ore oot gait analysis, 528 hind oot see hind oot hypotheses categories, 523–525 contributing actors, 524–525 direction o impairment, 524 intervention, 525 nature o disorder, 524
neurophysiological pain mechanisms, 524 precautions/ contraindications, 525 prognosis, 525 source o symptoms, 524 li estyle actors in disorders o , 519 mobility exercises, 549–551 balance board, 551, 551 in dorsi exion, 549–551, 550 motor control exercises, 551–555 sitting, 551–555 standing, 555, 555 movements, 514 axes and planes, 514 single joints, 514–515 passive movements, 528, 529 , 530–532 combined techniques, 546–549 dorsi exion, 530, 530 plantar exion, 530, 530 pronation, 531–532, 531 supination, 530–531, 531 see also ore oot; hind oot, above physical examination, 525–528, 526t active movement, 528 unctional tests, 527–528 observation o gait, 528 observation in non-weight bearing, 525–527 observation in weight bearing, 527, 527 passive movement, 528, 529 planning, 523–525 provocation tests, 528 psychosocial actors in injury, 518–519 rays, 515 rotation, 536–537 inversion/ eversion, 537, 538 lateral, 547–548, 547 medial/ lateral, 517, 536–537 subjective examination, 520–523 history, 522–523 patient behaviour, 522–523 re ection on, 523 screening questions, 523 symptom areas, 521 symptom behaviour, 522 type o disorder, 520–521 therapeutic exercises, 549 treatment, 528–555, 529 work-related actors, 519–520 see also individual joints ore oot accessory movements, 544–546 activation o , 551–553, 552 –553 dorsi exion, 535, 535 , 546–547, 546 passive movement, 534–536 plantar exion, 534, 534 pronation, 536, 536 supination, 535–536, 535 see also oot/ ankle
581
Inde x ractures, 98, 266, 272 rozen shoulder, 148t, 155–156, 200t–202t clinical eatures, 200 diagnosis, 200 management, 200 onset and aetiology, 200 pathology, 200 physiotherapy implications, 200 unction, 67 unctional corners, 288, 290, 371, 414, 490 unctional demonstration, 8, 11, 12 craniomandibular complex, 105, 105 elbow, 272–275 oot/ ankle, 527–528 hand/ wrist, 325–326, 333 knee, 466 radioulnar joint, 325–326 unctional MRI, craniomandibular disorders, 101
G gait analysis oot/ ankle pain, 528 hip pain, 394–395 knee pain, 466 gastrocnemius, length, 470 gate control theory o pain, 78 gemelli, 434–435, 435 superior/ in erior, 382b genu recurvatum, 465 giving way o knee, 461–462 glenohumeral joint, 228b–229b mobilization, 250 physical examination, 228b–229b see also shoulder glenohumeral osteoarthritis, 203t–204t clinical eatures, 203t–204t diagnosis, 203t–204t management, 203t–204t onset and aetiology, 203t–204t pathology, 203t–204t physiotherapy implications, 203t–204t glenoid labrum imaging studies, 161 pathology, 153–155 glide cervical lateral, 312, 312 side, 241 elbow lateral, 303–306, 305 , 307 longitudinal caudad, 308, 309 medial, 303–304, 305 , 306–307, 307 hip anterior, 416, 416 lateral, 417 posterior, 414–417, 415 , 417 global mobilizers, 381t hip, 382b, 436–437 lumbar areas, 382b
582
tests, 406 see also individual muscles global stabilizers, 381t hip, 382b, 435–436 lumbar area, 382b tests, 403 see also individual muscles gluteus maximus, 382b, 436 deep, 404, 404 superior, 406, 407 gluteus medius, 382b anterior, 405, 405 posterior, 385–391, 404–405 gluteus minimus, anterior, 405, 405 goal-setting, 43–44, 75 gol er’s elbow, 263 gracilis, 382b grades o mobilization/ manipulation, 293–295, 297–299 grip strength tests, 337–338
H hamstrings, 436 injury, treatment, 386t–387t length, 470 tests, 406, 406 hand/ wrist, 324–374 active movement, 333–337 body charts, 329 , 373 bones, 327, 327 –328 case study, 372b–374b chronic symptoms, 371b compression see compression, hand/ wrist dermatomes, 338 extension see extension, hand/ wrist exion see exion, hand/ wrist unctional demonstration, 325–326 nerve supply, 338 –339 see also individual nerves pain mechanisms, 326 input, 326 output, 326 processing, 326 palpation, 338 passive movements, 339 physical examination, 330–372, 331b carpometacarpal joint o thumb, 336b carpometacarpal joints, 334b composite, 336b–337b unctional demonstration, 333 horizontal exion/ extension, 339 intercarpal joints, 333b intermetacarpal movement, 334b–335b interphalangeal joints, 335b metacarpophalangeal joints, 335b movements reproducing pain, 338 neurological examination, 338 observation, 331–333 radial and ulnar deviation, 339 radioulnar joint, 331b–332b in supine lying, 338, 338
wrist joint, 332b see also tests, below pisi orm movements, 359–360, 359 pronation, 339, 342 radiocarpal, 353–354, 354 radioulnar, 275 , 298 range o motion, 327–328, 327 screening, 371, 371b subjective examination, 328–330 areas o symptoms, 329–330, 329 history, 330 screening questions, 330 symptom behaviour, 330 type o disorder, 328 supination, 339 radiocarpal, 340 –341 , 352–353, 353 radioulnar, 298 , 340 –342 whole hand, 340 symptom origin, 325 tactile unction, 325 tests i necessary, 337–371 isometric (grip strength) tests, 337–338 neurodynamic, 338 treatment, 371–372 see also individual joints H awkins-Kennedy test, 143, 153 , 157, 223t–226t healthy li e expectancy, 4b healthy living, 4, 4t, 52 , 54 bio-psychosocial paradigm, 52 , 54 hearing, 6 hearsay evidence, 69t heel pain see plantar asciitis heels, sitting on, 467 H ill-Sachs lesions, 194t–196t hind oot accessory movements, 537–544 dorsi exion, 532–533, 533 and compression, 547, 547 and lateral rotation, 547–548, 547 integrative plantar exion, 554–555, 554 passive movement, 532–534, 537–544 plantar exion, 532–534, 532 pronation, 533–534, 534 dissociative, 554, 554 supination, 533, 533 dissociative, 553–554, 553 see also oot/ ankle hip, 375–449 abduction in supine, 400, 400 in treatment, 431–432, 431 accessory movements, 380, 414–417 in treatment, 417–425 active movements, 394–395 ascending/ descending steps, 396 sitting, 397 squatting, 396 standing, 395–396, 395
In d e x step-down test, 396, 396 supine and prone positions, 397–402 swing movement, 395 in treatment, 433–437, 433b–434b trunk movements, 396 weight bearing, 395, 395 adduction, 411–413, 412 –415 , 416 in supine, 400–401, 401 applied theory, 379–385 structural- unctional integration, 379–381, 379 body charts, 388 , 444 case study, 443b–447b clinical syndromes athlete’s groin, 377t–378t, 386t–387t, 439t–440t meralgia paraesthetica, 442t–443t osteoarthritis, 377t–378t, 385t–386t, 437t–438t torn acetabular labrum, 440t–441t trochanteric bursitis, 377t–378t, 441t–442t components o disorders, 375–379 unctional causes, 375–376, 377t–378t pathobiology, 376–379, 383 structural sources, 375, 376t, 393t evidence-based practice, 385, 385t–386t extension see extension, hip exion see exion, hip global mobilizers, 382b, 406, 436–437 global stabilizers, 382b, 403, 435–436 motor control, 383, 383 muscles classif cation, 381, 381b, 381t imbalance, 381–383, 382 see also specif c muscles palpation, 410–411 passive movement, 411–414 physical examination, 391–417, 391b, 393t gait analysis, 394–395 observation, 392–393, 392b–393b, 392 progression o , 396 rotation see lateral rotation; medial rotation screening o other structures, 410 segmental stabilizers, 434–435 see also individual muscles subjective examination, 385–391 areas o symptoms, 388–389, 388 history, 389–390, 390t main problem, 387–388 special questions and screening questions, 391 symptom behaviour, 389
tests, 394 adductors, 405–406, 405 , 409–410, 409 anterior gluteus medius/ minimus, 405, 405 deep gluteus maximus, 404, 404 di erentiation, 413, 414 hamstrings, 406, 406 iliacus, 403–404, 403 isometric, 402–403 modif ed O ber test, 408, 408 modif ed Thomas’ test, 407–408, 408 muscle length, 403 neurodynamic, 410 piri ormis, 409, 409 posterior gluteus medius, 404–405, 405 rectus emoris, 409, 409 relative exibility, 400, 400 screening, 471 slump test, 410 stability, 416 step-down, 396, 396 superior gluteus maximus/ iliotibial tracts, 406, 407 tensor ascia lata in standing, 406–407, 407 treatment, 383–385, 384 , 417–433 accessory movements, 417–425 active movement, 433–437, 433b–434b exion/ adduction, 425–426, 425 hip dysplasia, 390 history taking, 8, 569, 570 craniomandibular disorders, 99–102 elbow pain, 266 oot/ ankle pain, 522–523 hand/ wrist pain, 330 hip pain, 389–390, 390t knee pain, 463 see also subjective examination hopping, 467 horizontal extension, 339, 355 horizontal exion, 339, 356, 356 H ornblower’s test, 151, 152 , 223t–226t humeral head, posteroanterior movement, 156 humeroulnar joint, 262 compression, 274 normal movement, 262 physical examination, 270b see also elbow hyoid examination o , 121–122, 121 see also craniomandibular complex hyperalgesia, 44t, 278 hyperextended knees, 465 hypermobility hip joint, 377t–378t treatment, 386t–387t hypotheses categorization, 523–525 hypothetico-deductive reasoning, 11–12
impairment, 5 pathobiological, 4–5
I ICD, and ‘brick wall’ concept, 53–54 ICF, 2–3, 34, 50, 73, 324 bio-psychosocial paradigm, 43, 43 , 50–54 and ‘brick wall’ concept, 53–54, 54t model o , 68 movement continuum theory see movement continuum theory and physiotherapy diagnosis, 66–68, 214, 215 i necessary tests elbow, 275–277 hand/ wrist, 337–371 hip, 468, 469 knee, 468, 469 IFO MPT, 2, 46–47 iliacus, 382b iliacus test, 403–404, 403 iliocostalis, 382b iliotibial tractitis, 377t–378t iliotibial tracts, 406, 407 illness experience, 75–76 illness perception, 70 imaging studies shoulder pain, 159–162 limitations o , 161–162 rotator cu integrity, 159–160 subacromial impingement, 160–161 use o , 159 see also specif c modalities impairment hypothesis, 5 impairment-based treatment, 183b–184b impairments, 67 indicators o change, 39, 39b in erior instability see sulcus sign in erior radioulnar joint compression, 343, 343 unctional demonstration, 325–326 longitudinal movement caudad/ cephalad, 344, 344 pain, 329 physical examination, 331b–332b posteroanterior/ anteroposterior movement, 339–343, 342 pronation, 342 supination, 340 –341 in ammation, 215–216 in raspinatus test, 151 inguinal nerve entrapment, 377t–378t initial assessment, 34–35 injuries elbow, 313 shoulder, 216 temporomandibular joint, 99–100
583
Inde x instability ankle, 516–517 knee, 462 shoulder, 148t, 155, 207t–209t, 215 intercarpal joints, 325–326 extension, 355 exion, 356, 356 physical examination, 333b posteroanterior/ anteroposterior movement, 357–358, 357 intercostal movement, 233b intermetacarpal joints disorders, 329 movements, 334b–335b, 361–363, 362 intermetatarsal spaces, 514 International Classif cation o Functions, Disability and H ealth see ICF International Classif cations o Disease see ICD International Federation o O rthopaedic Manipulative Physiotherapists see IFO MPT interphalangeal joints, 514 abduction, 364–365, 364 adduction, 364–365, 364 circumduction, 363–364, 363 –364 , 369, 369 –370 extension, 363–364, 363 –364 , 369, 369 –370 exion, 363–364, 363 –364 , 369, 369 –370 longitudinal movement caudad/ cephalad, 366–367, 367 medial/ lateral rotation, 365–366, 365 –366 physical examination, 335b posteroanterior/ anteroposterior movements, 368, 368 interspinales, 382b intertarsal joints, 514–515 intertransversarii, 382b interventions, 2 intra-articular disorders, 98–99, 99t, 128t inversion, 429, 472 irritability, 55–56 def nition, 56b ischial bursitis, 377t–378t isometric tests elbow, 278 hand (grip strength), 337–338 hip, 402–403 knee, 468 temporomandibular joint, 112–113
J joints blocked, 380–381 costal, 233b locking, 462 replacement, 437t–438t, 457–461 see also specif c joints jumping, 467
584
K kinesiophobia, 517 Tampa scale, 520 knee, 450–511 abduction, 469 , 493 with extension, 489–490 with exion, 490–491 accessory movements, 493–498 active movement, 466–468 i necessary tests, 468, 469 non-weight bearing, 467–468 weight bearing, 466–467 adduction, 469 –470 , 493 with extension, 489–490 with exion, 490–491 anatomy, 451–452 body charts, 462, 505 case study, 504b–508b catching, 462 clinical reasoning, 461 clinical syndromes, 453–461 anterior knee pain, 457, 459t–460t osteoarthritis, 453–457, 458t–459t compression, 485b–487b, 486 evidence-based practice, 451–461 extension see extension, knee exion see exion, knee instability, 462 locking, 462 momentary pain, 484–488 motor control, 452 movement diagram, 475 movement patterns, 452 muscle tests, 468–470 length, 470 recruitment patterns, patellar alignment and symptom production, 468–469, 470 nerve supply, 453 palpation, 474–475 e usion, 474 swelling, 462, 474 temperature, 474 tenderness, 474–475, 475 passive movement, 475–481 physical examination, 463–481, 464b alignment, 464–466 brie appraisal, 466 di erentiation procedures, 466 unctional demonstration, 466 observation, 464–466 present pain, 464 see also tests, below range o motion, 452–453 replacement, 457–461 rotation see rotation, knee stability and mobility, 452, 475, 475b–477b sti ness, 483–484 subjective examination, 461–463 areas o symptoms, 462 history, 463
main problem, 462 screening questions, 463 symptom behaviour, 462–463 techniques, 488–504 tests di erentiation, 466 emoral nerve test, 471, 471 i necessary, 468, 469 isometric, 468 muscles, 468–470 navicular drop test, 465 neurodynamic, 464, 471b–474b Patrick’s test, 471 saphenous nerve test, 471, 472 sciatic nerve, 472–474, 472 screening, 470–471 step-up/ step-down, 466 treatment, 481–488 group 1 patients, 482–483 group 2 patients, 483 group 3 patients, 483–484 group 4 patients, 484–488 selection, 481–482 knowledge base, 47
L Lachmann’s test, 476 larynx examination o , 121–122, 121 see also craniomandibular complex lateral epicondylalgia, 261–263, 266, 275, 316 clinical prof le, 314t–315t exercise therapy, 267 presentation, 316b techniques or, 309–312 gripping with lateral glide, 310–311, 310 gripping with radius posteroanterior glide, 311–312, 311 lateral emoral cutaneous nerve entrapment, 377t–378t lateral glide cervical, 312, 312 elbow extension, 303, 305 exion, 304–306, 307 gripping with, 310–311, 310 hip, 417 lateral movement hip, 417–419, 418 knee, 497, 497 lateral rotation oot/ ankle, 517, 536–537, 547–548, 547 hand/ wrist, 365–366, 365 –366 hip, 399, 430–431, 430 interphalangeal joints, 365–366, 365 –366 metacarpophalangeal joints, 365–366, 365 –366
In d e x Leeds Assessment or Neuropathic Symptoms and Signs (LANSS) scale, 279 levels o evidence, 69t listening, 75 local stabilizers, 381b, 381t hip and lumbar area, 382b locking joints, 462 locus o control, 44t long adductors, 437 long thoracic nerve entrapment, 172t–174t longissimus, 382b longitudinal movement hand/ wrist, 358 intercarpal joints, 358–359, 358 tibio emoral joint, 493 longitudinal movement caudad craniomandibular complex, 117–118, 118 elbow, 295–296, 295 –297 head o radius, 301, 302 hip, 419–421, 420 in erior radioulnar joint, 344, 344 interphalangeal joints, 366–367, 367 knee, 493–494 metacarpophalangeal joints, 366–367, 367 patello emoral joint, 500–501, 500 radioulnar joint, 344, 344 shoulder, 248 superior tibiof bular joint, 503–504 temporomandibular joint, 117–118, 118 , 126 longitudinal movement cephalad craniomandibular complex, 120–121 head o radius, 301, 302 hip, 422–423, 423 in erior radioulnar joint, 344, 344 interphalangeal joints, 366–367, 367 knee, 493–494 metacarpophalangeal joints, 366–367, 367 occiput-C1 longitudinal technique, 123–124, 124 patello emoral joint, 500–501, 500 radioulnar joint, 344, 344 superior tibiof bular joint, 503–504 temporomandibular joint, 120–121 loose bodies, 313, 388 low back pain, 56 lumbar spine screening hip pain, 410 knee pain, 471
M McMurray’s test, 477 magnetic resonance imaging see MRI Maitland Concept, 1–65 as clinical practice ramework, 1–3, 3 research, 54–62 shoulder pain, 219–233, 219
make eatures f t principle, 462–463 maladaptive behaviours, 44t malocclusion, 115, 116 manageability, 76 mandible anteroposterior/ posteroanterior movement, 119–120 distraction, 126 overpressure, 107 , 110 –111 protraction, 109, 110 resting position, 89–91 retraction, 109–112, 110 –112 see also temporomandibular joint mandibular condyle tumours, 96 mandibular nerve, neurodynamic testing, 113–114 manipulation, 28–29, 28 –29 bio-psychosocial paradigm in, 52–53, 53b biomedical paradigm in, 53b def nition, 55b dosage parameters, 58 grades o , 56–58, 293–295, 297–299 techniques, 59t see also O MT; and specif c areas manual testing, 20 masseter muscle hypertrophy, 104 relaxation therapy, 129 matrix metalloproteinases (MMPs), 189t–192t mature organism model o pain, 81 maxilla, examination o , 126, 126 meaning ulness, 76 mechanosensitivity, 29, 114, 177, 275, 286 medial cunei orm, anteroposterior movement, 545, 545 medial epicondylalgia (gol er’s elbow), 263 medial glide elbow extension, 303–304, 305 exion, 306–307, 307 medial movement, knee, 497, 497 medial rotation oot/ ankle, 517, 536–537 hip, 426–430, 427 –428 interphalangeal joints, 365–366, 365 –366 knee, 491 metacarpophalangeal joints, 365–366, 365 –366 medial transverse movement craniomandibular complex, 116–117, 117 , 120 hand/ wrist, 355 median nerve, 263, 339 cutaneous supply, 329 palpation, 286, 287 tests, 280, 281 active screening, 281 medical diagnosis, 144, 145 , 168 triage process, 169 meniscus testing, 464b, 475 meralgia paraesthetica, 442t–443t
meta-analysis, 69 metacarpophalangeal joints, 325–326 abduction, 364–365, 364 adduction, 364–365, 364 circumduction, 363–364, 363 –364 , 369, 369 –370 extension, 363–364, 363 –364 , 369, 369 –370 exion, 363–364, 363 –364 , 369, 369 –370 longitudinal movement caudad/ cephalad, 366–367, 367 physical examination, 335b posteroanterior/ anteroposterior movements, 368, 368 rotation, 365–366, 365 –366 metacognition, 9 metatarsophalangeal joints, 514 f rst, 515 movement, 515 midcarpal joints, 350 extension, 348–349, 348 exion, 346, 346 midtarsal joint, 514 anteroposterior movement, 544, 544 normal movements, 515 transverse medial movement, 544–545, 544 mobilization, 28–29, 28 –29 def nition, 55b dosage parameters, 58 grades o , 56–58, 57b, 293–295, 297–299 techniques, 59t see also entries under movement mobilization with movement (MWM), 262, 266–268, 277 , 284–285, 301–309 lateral epicondylalgia, 310–312, 310 –311 motor control hip, 383, 383 knee, 452 mouth closing, 109, 109 mouth opening, 106–108, 134 bilateral condylar palpation, 107 bilateral longitudinal cephalad pressure, 108 hold-relax technique, 107 intraoral massage technique, 107 overpressure, 107 transverse medial pressure, 108 movement active see active movement tests combined, 546–549 diagrams, 58–59, 60 directions, 66–67 paradigms, 72, 73 passive see passive movements patterns, 433, 433b–434b, 452 potential, 50–51 see also mobilization movement continuum theory, 50–51, 51 , 66, 67 and ICF, 51–52, 51b, 52
585
Inde x movement dys unctions, 35–36, 44 hip disorders, 375–376, 379–381 accessory movements, 380 protective reactions, 380 restriction, 380–381 physiological, 380 types o , 14 movement sciences, 72–83 MRI, shoulder pain, 159–160 MRI arthrography, 161 Mulligan Concept, 262, 266–268, 285 multicomponent movement disorders, 44 multif dus, 382b muscles classif cation, 381, 381b–382b, 381t f bres, 378t, 383 imbalance, 381–383, 382 length hip, 403 knee, 470 tests hip, 403 knee, 468–470 see also individual muscles MWM see mobilization with movement myo ascial pain, 215–216 myo ascial structures, 376
N narrative clinical reasoning, 21 navicular drop test, 465 negative likelihood ratio, 149t–150t nerves entrapment, 29, 29 hand/ wrist, 338 –339 knee, 453 palpation, 473–474, 473 tests see neurodynamic tests see also individual nerves nervi nervorum, 278–279 neurodynamic mobilization elbow, 312–313 cervical lateral glide, 312, 312 scaphoid IV and V, 312–313, 313 neurodynamic tests arms, 278–282 hand/ wrist, 338 hip, 410 knee, 464, 471b–474b neurological examination craniomandibular complex, 113 elbow, 285–286 hand/ wrist, 338 neuropathic pain, 6 neuropathic sensory hypersensitivity, 278–279 neurophysiological paradigms, 78–81 pain mechanisms, 79–81, 79t–80t nociception, 79t–80t nociceptive pain back, 82t hand/ wrist, 326
586
non-weight bearing tests, 467–468 nonverbal communication, 6–7 nucleus trigeminocervicalis, 93
O O -P (overpressure), 563 hip, 397–402 knee, 467 –469 mandible, 107 , 110 –111 mouth opening, 107 O ber test, modif ed, 408, 408 obliquus internus/ externus, 382b O ’Brien’s active compression test, 154 , 157, 223t–226t observation, 8 craniomandibular complex, 102–103 elbow, 272 oot/ ankle, 525–528, 527 hand/ wrist, 331–333 hip, 392–393, 392b–393b, 392 knee, 464–466 obturator nerve, 434–435, 435 internus/ externus, 382b occipital nerve, major test, 113 occlusal-cervical-pelvic relationships, 122 odontogenic pain, 95 O MT, 42b, 46–47 Ö rebro musculoskeletal pain questionnaire, 520 oro acial pain, 88–89 orthodontics, 88 orthopaedic manipulative therapy see O MT O sgood-Schlatter’s disease, 474 osteitis pubis, treatment, 386t–387t osteoarthritis acromioclavicular, 210t–212t elbow, 313 glenohumeral, 203t–204t hip, 377t–378t, 437t–438t treatment, 385t–386t knee, 453–454, 458t–459t treatment, 455–457 osteochondrosis, elbow, 313 outcome measures, 30–33, 67 outcomes, 8, 54 overbite, 103 overpressure see O -P (overpressure) overuse disorders, 376
P pain central, 261–262 coping strategies, 562 def nitions, 81 elbow, 317, 317b end-o -range, 99t, 128t, 162b experience, 81 oot/ ankle, 517–518 gate control theory, 78 hand/ wrist, 371b integrative dynamic models, 81 mechanisms, 79–81, 79t–80t
odontogenic, 95 perception, 79t–80t re erred shoulder, 216 somatic, 82t source o , 157 sympathetically maintained, 326 through-range, 282–284, 294, 300 types o , 82t see also specif c types pain ul arc syndrome, 146–147 palpation, 8 craniomandibular complex, 92 , 114–116 elbow, 278–282, 279 , 286 hand/ wrist, 338 hip, 410–411 knee, 474–475, 475 nerves, 473–474, 473 temporomandibular joint, 92 , 114–116 see also individual areas Panjabi’s three subsystem model o stability, 88, 91, 94 Panner’s disease, 313 paradigms bio-psychosocial see bio-psychosocial paradigm biomedical see biomedical paradigm ‘brick wall’ see ‘brick wall’ model to movement, 72, 73 paralleling, 568 Parsonage-Turner syndrome, 172t– 174t, 371–372 participation, 67 participation restrictions, 4t, 5, 67 passive movements, 11, 51 assessment during, 40 def nition, 55b elbow, 282–284, 282 –284 , 286–301 oot/ ankle, 528, 529 , 530–532 hand/ wrist, 339 hip, 411–414 knee, 475–481 record keeping, 572–573, 573 research, 55, 55b passive testing, 8 patellar alignment, 468–469 patello emoral joint, 478–479, 478 –479 accessory movements, 498–502 compression, 498–499, 498 distraction, 499 exion, 501–502, 502 longitudinal movement caudad/ cephalad, 500–501, 500 pain, 485–488 transverse medial/ lateral movement, 499–500, 499 patello emoral pain syndrome, 461 pathobiological hypothesis, 4–5 pathogenic perspective, 76, 77t patient reported outcome measures see PRO Ms
In d e x Patient Specif c Functional Scale (PSFS), 265 patient-centred practice, 2, 4–9, 75 clinical reasoning, 10–13 communication, 6–7 healthy living, 4, 4t patients behaviour o , 39b, 75 clinical groupings, 30, 30 compliance enhancement, 83 experience o , 4–5 participation in decision making, 5–6 sel -management, 30, 558–564 cognitive-behavioural approach, 559–560, 559 compliance see compliance written records, 575 Patrick’s test, 471 pattern recognition, 74 pectineus, 382b tests, 405–406, 405 pelvic tilt, anterior, 465 periarticular disorders, 95 , 99t periarticular joints, 410, 461, 463 peripheral joints subjective examination, 227b see also individual joints peripheral nerve entrapments, 172t–174t see also specif c nerves peripheral nerve sensitization, 278–279 personal actors, 67 Perthes’ disease, 390 phases o change, 560–561, 560t long-term compliance, 561 motivational phase, 560–561 short-term compliance, 561 phenomenological perspective, 75–78, 78 physical examination, 2, 13–28 acromioclavicular joint, 230b–231b acromiohumeral joint, 229b–230b carpometacarpal joints, 334b, 336b clinical standards, 47b–49b communication during, 20 craniomandibular complex, 102–112, 103b elbow, 268–313, 268b–269b, 317–318 oot/ ankle, 525–528, 526t glenohumeral joint, 228b–229b hand/ wrist, 330–372, 331b hip, 391–417, 391b, 393t humeroulnar joint, 270b in erior radioulnar joint, 331b–332b initial, 36b intercarpal joints, 333b interphalangeal joints, 335b knee, 463–481, 464b manual testing, 20 metacarpophalangeal joints, 335b order and structure, 21–27, 22b–25b per orming, 27–28, 38b planning, 27–28, 36b procedures, 26b
radiohumeral joint, 269b reasoning strategies, 27, 27b reassessment see reassessment record keeping, 570 red ags, 26b shoulder, 149–158, 222–232 sternoclavicular joint, 231b superior radioulnar joint, 271b yellow ags, 26b see also subjective examination; tests/ testing; and specif c regions physical tests diagnostic accuracy, 151 see also specif c tests physiotherapists as autonomous practitioners, 2 as educators, 83 role o , 144–146 physiotherapy shoulder pain, 213–233 see also specif c conditions physiotherapy diagnosis, 144–145 shoulder pain, 213–214 APTA perspective, 215–216 clinical prediction rules, 217–219 ICF perspective, 66–68, 214, 215 subgrouping classif cation, 216–218 see also diagnosis pillars o carpal bones, 327–328, 327 piri ormis, 382b, 437 tests, 409, 409 piri ormis syndrome, 386t–387t pisi orm movements, 359–360, 359 pivot shi t test, 476 planning sheet or examination, 22b–25b plantar asciitis, 516 plantar heel pain syndrome, 516 polymyalgia rheumatica, 176t popliteus, 452 position o hands see specif c techniques positive likelihood ratio, 149t–150t post-test probability, 149t–150t posterior drawer test, 476 posterior glide o hip excessive, 416–417, 417 restricted, 414–416, 415 posterior gluteus medius test, 404–405, 405 posterior interosseous nerve, 263 posterior pelvic tilt, 131 posterior sag sign, 476 posteroanterior accessory mobilization o shoulder, 236 , 247 posteroanterior movement craniomandibular complex, 119–120 distal tibiof bular joint, 538–539, 538 hip, 421–422, 421
intercarpal joints, 357–358, 357 interphalangeal joints, 368, 368 knee, 494–495, 494 mandible, 119–120 metacarpophalangeal joints, 368, 368 radiocarpal joint, 351–352, 351 radioulnar joint, 339–343, 342 subtalar joint, 542, 542 , 546, 546 superior tibiof bular joint, 503 talocrural joint, 540, 540 posture correction o , 433, 433b–434b and craniomandibular disorders, 100 and hip disorders, 392–393, 392b–393b, 392 pre-experimental studies, 69t precautions/ contraindications craniomandibular complex, 113–114 elbow, 272 oot/ ankle, 525 pre erred practice patterns, 215–216 prepatellar bursitis, 474 pretest probability, 149t–150t primary care, shoulder pain diagnosis, 180–181 processing model o pain, 81 prognosis, 5, 41–46, 74 goal-setting see goal-setting ICF bio-psychosocial paradigm, 43, 43 phases o , 42b types o disorders, 44t PRO Ms, 5–6 pronation elbow, 273 –275 , 297, 298 grade IV, 299 grades II, III and IV, 297–299 oot/ ankle, 531–532, 531 ore oot, 536, 536 hand/ wrist, 339, 342 hind oot, 533–534, 534 protraction o mandible, 109, 110 psoas, 382b, 434, 434 psychosocial actors catastrophizing, 182, 518 oot/ ankle pain, 514–515, 518–519 and neurophysiological pain mechanisms, 519 shoulder pain, 182
Q Q UADAS (Q uality Assessment o Diagnostic Accuracy Studies), 149–151 quadratus emoris, 382b tests, 405–406, 405 quadratus lumborum, 382b quadriceps active test, 476 quadriceps angle (Q -angle), 465 quasi-experimental studies, 69t questioning, 7 screening questions, 8 semistructured interview, 9 questionnaires, 567–568
587
Inde x
R radial deviation, 350–351, 350 radial nerve, 339 palpation, 286, 287 tests, 280–281, 281 active screening, 281 radicular pain, 81, 82t radiculopathy, 82t, 521 radiocarpal joint, 325–326 anteroposterior movement, 352, 352 disorders, 329 extension, 347–348, 347 exion, 345–346, 345 lateral transverse movement, 354 medial transverse movement, 355 mobilization, 349–350 posteroanterior movement, 351–352, 351 pronation, 353–354, 354 supination, 340 –341 , 352–353, 353 radiography, pain, 160 radiohumeral joint, 262–263 compression, 274 –275 distraction, 276 physical examination, 269b see also elbow radioulnar joint, 262 in erior see in erior radioulnar joint pronation, 275 superior see superior radioulnar joint supination, 340 –341 see also elbow radius, head o anteroposterior movement, 300, 302 longitudinal movement caudad, 301, 302 in pronation, 300–301 in supination, 300, 302 randomized clinical trials (RCTs), 69, 69t range o motion hand/ wrist, 327–328, 327 knee, 452–453 temporomandibular joint, 98, 99t, 128t reasoning clinical see clinical reasoning collaborative, 9 reasoning in action, 2 reasoning on action, 2 reassessment, 20–21, 37b, 59–62 ‘art’ o , 39–40 be ore/ a ter treatment, 38–40 clinical standards, 47b–49b indicators o change, 39, 39b record keeping, 565–576 active movements, 570–572 asterisks, 567, 567b body charts see body charts end o session instructions, 574
588
ollow-up, 574 general points, 567–568 history taking, 569, 570 passive movements, 572–573, 573 patient’s notes, 575 physical examination, 570 questionnaires, 567–568 retrospective assessment, 574–575 SOAP notes, 566–567 subjective examination, 568–569 symbols, 571t–572t symptom behaviour, 568–569 rectus abdominis, 382b rectus emoris, 382b, 437 length, 470 tests, 409, 409 red ags, 26b screening or, 169 shoulder pain, 169–170 re errals, 144 re erred pain shoulder, 216 somatic, 82t rehabilitation, 69–70 relative exibility test, 400, 400 relaxation splint, 102 relocation test, 156 repositioning splint, 102 research, 54–62 cognitive-behavioural paradigms, 83 irritability, 55–56, 56b osteoarthritis o knee, 455–457 passive movement, 55, 55b retraction o mandible, 109–112, 110 –112 retrognathy, 104 retrospective assessment, 41, 41b record keeping, 574–575 rheumatoid arthritis, elbow, 313 rotation cervical spine, 105 oot/ ankle, 536–537, 538 interphalangeal joints, 365–366, 365 –366 knee, 469 , 491–493 metacarpophalangeal joints, 365–366, 365 –366 see also lateral rotation; medial rotation rotator cu arthropathy clinical eatures, 189t–192t diagnosis, 189t–192t management, 189t–192t onset and aetiology, 189t–192t physiotherapy implications, 189t–192t rotator cu integrity, 151 imaging studies, 159–160 rotator cu tears, 148t, 189t–192t clinical eatures, 189t–192t diagnosis, 189t–192t management, 189t–192t onset and aetiology, 189t–192t pathology, 189t–192t physiotherapy implications, 189t–192t
rotator cu tendinopathy, 146–147, 148t, 189t–192t diagnosis, 164–168, 189t–192t extrinsic mechanisms, 165t–166t intrinsic mechanisms, 166t–167t onset and aetiology, 189t–192t pathology, 189t–192t physiotherapy implications, 189t–192t see also calcif c tendonitis rotatores, 382b
S sacroiliac region screening, 410 knee pain, 471 salutogenic perspective, 75–76, 77t saphenous nerve palpation, 473 testing, 471, 472 sartorius, 382b scapula dyskinesis, 187 scapulothoracic movement, 232b sciatic nerve test with emphasis on peroneal nerve, 472–474, 472 with emphasis on tibial nerve, 472, 472 scope o practice, 49 screening questions, 8 craniomandibular disorders, 101–102 oot/ ankle pain, 523 hip disorders, 391 knee pain, 463 screening tests, 74 elbow, 317, 317b hand/ wrist, 371 hip, 471 knee, 470–471 shoulder, 170–177 red ags, 169–170 triage process, 169 sel -management, 30, 558–564 cognitive-behavioural approach, 559–560, 559 compliance, 559 barriers to, 559 enhancement, 83, 561–563 long-term, 561 short-term, 561 phases o change, 560–561, 560t semistructured interview, 9 ‘sense-o -coherence’, 76 sensitivity practice, 149t–150t sensory homunculus, 324 shoulder, 142–260 assessment, 177b–179b body charts, 178 , 183 , 187 , 234 , 237 , 240 , 243 , 246 , 249 ‘brick wall’ model, 220–222, 221 case studies, 162b, 177b–179b, 183b–184b, 186b–188b, 232–233 diagnosis, 146–168, 180–188
In d e x accuracy o , 149–151, 149t–150t anatomical basis, 157 based on physical tests, 153 biomedical perspective, 146–158 changing knowledge, 164–168 dilemmas in, 180 ESP role, 168–169 ace validity, 157 H ornblower’s sign, 151, 152 Maitland Concept, 146 operational def nitions, 157 pain inhibition, 157 pain source, 157 physiotherapy-based see physiotherapy diagnosis, below primary care, 180–181 re erence test, 157–158 rotator cu integrity, 151 surgical f ndings, 162–163 terminology, 147b see also tests, below diagnostic labels, 146–149, 147b, 148t, 180–181 ESP role, 143–146, 168–188 assessment, 177b–179b practice and diagnosis, 168–169 external sources, 174t–176t ractures, 216 imaging studies, 159–162 glenoid labrum, 161 limitations o , 161–162 rotator cu integrity, 159–160 subacromial impingement, 160–161 use o , 159 instability, 148t, 155, 207t–209t, 215 aetiology and pathology, 207t–209t associated conditions, 207t–209t clinical eatures, 207t–209t diagnosis, 207t–209t management, 207t–209t physiotherapy implications, 207t–209t Maitland Concept, 219–233, 219 mobilization, 185 anteroposterior cervical accessory, 178 cervical side glide, 241 glenohumeral posteroanterior, 250 longitudinal caudad accessory, 248 posterioranterior accessory, 236 , 247 non-specif c pain, 213–214 peripheral nerve entrapments, 172t–174t persistent symptoms, 181–188 conservative management, 182–186 impairment-based treatment, 183b–184b psychosocial actors, 182 surgical options, 186–188, 186b–188b
physical examination, 149–158, 222–232 acromioclavicular joint, 155, 230b–231b acromiohumeral joint, 229b–230b algorithm, 233 composite shoulder, 227b–228b costal joints, 233b dynamic control, 278 rozen shoulder, 155–156 glenohumeral joint, 228b–229b glenoid labrum pathology, 153–155 instability, 155 scapulothoracic movement, 232b sternoclavicular joint, 231b physiotherapy diagnosis, 213–214 APTA perspective, 215–216 clinical prediction rules, 217–219 ICF perspective, 66–68, 214, 215 subgrouping classif cation, 216–218 physiotherapy perspective, 213–233 re erred, 216 screening, 169 conditions requiring early medical attention, 170–171 extrinsic sources, 171–177 red ags, 169–170 sti ness, 249b subjective examination, 227b surgery, 216 tests, 151 anterior release test, 156 apprehension test, 156 belly-press test, 151, 152 , 223t–226t biceps load tests, 154 , 223t–226t crank test, 155 , 223t–226t diagnosis based on, 153 empty can test, 153 , 223 external rotation lag sign, 152 , 223t–226t H awkins-Kennedy test, 143, 153 , 157, 223t–226t H ornblower’s test, 151, 152 , 223t–226t O ’Brien’s active compression test, 154 , 157, 223t–226t relocation test, 156 see also specif c conditions and parts shoulder impingement syndromes, 148t, 194t–196t internal, 194t–196t subacromial impingement see subacromial impingement shoulder quadrant, 184 mobilizations, 185 shoulder symptom modif cation procedure (SSMP) model, 217 sitting tests, 397 skills, 47
SLAP (superior labrum anterior posterior) lesions, 167–168, 187, 194t–196t, 205t–206t, 222 associated conditions, 205t–206t clinical eatures, 205t–206t diagnosis, 205t–206t, 223t–226t management, 205t–206t onset and aetiology, 205t–206t pathology, 205t–206t physiotherapy implications, 205t–206t slump test cervical spine, 113 hip, 410 knee, 471, 472 side lying, 471, 472 SOAP notes, 566–567 soleus, length, 470 somatic re erred pain, 82t SPADI (shoulder pain and disability index) score, 154 special questions elbow disorders, 266 hip disorders, 391 specif city, 149t–150t sphenoid bone, 126–127, 126 –127 spinal accessory nerve entrapment, 172t–174t spinal conditions, and shoulder pain, 174t–175t spinales, 382b splints, temporomandibular joint, 101 squatting hip pain, 396 knee pain, 467 stages o change model, 83 standards o clinical practice, 47b–49b standing on one leg, 466 with hal / ull exion test, 466 with rotation test, 466 standing tests, 395–396, 395 STARD (Standards or Reporting o Diagnostic Accuracy Studies), 149–151 statistical concepts in diagnosis, 149t–150t step-down test hip pain, 396, 396 knee pain, 466 step-up test, 466 sternoclavicular joint, 231b physical examination, 231b sti ness elbow, 316–317 knee, 483–484 shoulder, 249b stomatognathic muscles, palpation, 114–115 structural di erentiation, 8 subacromial bursa, 194t–196t subacromial impingement, 153, 158, 194t–196t case study, 234b–236b, 245b–248b clinical eatures, 194t–196t diagnosis, 194t–196t
589
Inde x imaging studies, 160–161 management, 194t–196t onset and aetiology, 194t–196t pathology, 194t–196t physiotherapy implications, 194t–196t subjective examination, 2, 20, 21b, 39b, 77t clinical standards, 47b–49b craniomandibular complex, 94–102 elbow, 263–266 oot/ ankle, 520–523 hand/ wrist, 328–330 hip, 385–391 knee, 461–463 peripheral joints, 227b record keeping, 568–569 shoulder, 227b see also physical examination; and specif c regions subtalar joint, 514 accessory movements, 541 anteroposterior movement, 542, 542 , 548, 548 distraction, 542–543, 542 dorsi exion, 546, 546 normal movements, 515 plantar exion, 548, 548 posteroanterior movement, 542, 542 , 546, 546 transverse medial movement, 543, 543 see also oot/ ankle sulcus sign, 207t–209t superior radioulnar joint compression, 276 physical examination, 271b posteroanterior/ anteroposterior movement, 302 pronation, 298 supination, 298 superior tibiof bular joint, 480–481, 480 –481 accessory movements, 502–504 anteroposterior movement, 502–503 longitudinal movement caudad/ cephalad, 503–504 pain, 488, 488 posteroanterior movement, 503 supination elbow, 273 –274 , 283 , 296–297, 298 oot/ ankle, 530–531, 531 ore oot, 535–536, 535 hand/ wrist, 339, 340 –341 hind oot, 533, 533 suprascapular nerve entrapment, 172t–174t supraspinatus tendinopathy, 164 surgery knee replacement, 457–461 shoulder arthroplasty, 216 shoulder pain, 186–188, 186b–188b surgical diagnosis in shoulder pain, 162–163 swelling, knee, 462, 474
590
swing movement, 395 symbols, 571t–572t sympathetically maintained pain, 326 symptoms area o see area o symptoms behaviour see behaviour o symptoms mechanisms o , 11 source o , 11 systematic review, 69t
T T4 syndrome, 326 tactile unction, 325 talocrural joint, 512, 514 accessory movements, 540 normal movements, 514–515 Tampa scale o kinesiophobia, 520 tarsometatarsal joint, 514–515 taxonomy, 67–68, 68 techniques manipulation, 59t mobilization, 59t teeth, 88 inspection o , 115–116 malocclusion, 115, 116 occlusion see occlusion temperature, knee, 474 temporal bone examination o , 124 bilateral caudo-lateral, 124, 125 bilateral circum erential, 124, 124 bilateral medial-lateral, 124, 124 temporomandibular joint, 88 axial movements, 91–94 clicking, 96–97 distraction, 101, 126 examination o , 125 unctional anatomy, 89–90, 90 innervation, 90 internal derangement, 97 –98 isometric tests, 112–113 occlusal-cervical-pelvic relationships, 122 palpation, 92 , 114–116 Panjabi’s three subsystem model o stability, 88, 91, 94 see also craniomandibular complex tenderness, knee, 474–475, 475 tennis elbow see lateral epicondylalgia tensor ascia lata, 382b, 436–437 length, 470 tests modif ed O ber test, 408, 408 in standing, 406–407, 407 tests/ testing abduction (valgus) stress test, 476–477 adduction (varus) stress test, 477 anterior drawer test, 475 Appley’s grind test, 477 elbow di erentiation, 285 i necessary, 275–277
MWM, 277 , 284–285 neural di erentiation, 277 neurodynamic, 278–282 hand/ wrist i necessary, 337–371 isometric (grip strength) tests, 337–338 neurodynamic, 338 hip, 394 adductors, 405–406, 405 , 409–410, 409 anterior gluteus medius/ minimus, 405, 405 deep gluteus maximus, 404, 404 di erentiation, 413, 414 global mobilizers, 406 global stabilizers, 403 hamstrings, 406, 406 iliacus, 403–404, 403 isometric, 402–403 modif ed O ber test, 408, 408 modif ed Thomas’ test, 407–408, 408 muscle length, 403 neurodynamic, 410 piri ormis, 409, 409 posterior gluteus medius, 404–405, 405 rectus emoris, 409, 409 relative exibility, 400, 400 slump test, 410 superior gluteus maximus/ iliotibial tracts, 406, 407 tensor ascia lata in standing, 406–407, 407 knee, 466 emoral nerve test, 471, 471 i necessary, 468, 469 isometric, 468 muscles, 468–470 navicular drop test, 465 Patrick’s test, 471 saphenous nerve test, 471, 472 sciatic nerve, 472–474, 472 step-up/ step-down, 466 Lachmann’s test, 476 McMurray’s test, 477 pivot shi t test, 476 posterior drawer test, 476 quadriceps active test, 476 screening see screening tests shoulder, 151 anterior release test, 156 apprehension test, 156 belly-press test, 151, 152 , 223t–226t biceps load tests, 154 , 223t–226t crank test, 155 , 223t–226t diagnosis based on, 153 empty can test, 153 , 223 external rotation lag sign, 152 , 223t–226t H awkins-Kennedy test, 143, 153 , 157, 223t–226t H ornblower’s test, 151, 152 , 223t–226t
In d e x O ’Brien’s active compression test, 154 , 157, 223t–226t relocation test, 156 slump test cervical spine, 113 hip, 410 knee, 471, 472 side lying, 471, 472 therapists see physiotherapists Thomas’ test, 20–21 modif ed, 407–408, 408 thoracic outlet syndrome, 172t–174t, 329 thoracic spine screening in hip pain, 410 and shoulder pain, 174t–175t through-range pain, 282–284, 294, 300 thumb carpometacarpal joint, 336b symptoms, 371b see also hand/ wrist tibial condyles, 451 tibial nerve, palpation, 473 tibio emoral angle, 465 tibio emoral joint, 477–478 anteroposterior movement, 496 extension, 488–489, 488 longitudinal movements, 493 mobilization, 28 , 478 , 487 pain, 485 posteroanterior movement, 494 rotation, 491 treatment under compression, 498, 498 Tinel’s sign, 279–280 tissue inhibitors o metalloproteinases (TIMPs), 189t–192t tongue inspection o , 116 resting position, 116
transverse movement craniomandibular complex, 116–117, 117 , 120 midtarsal joint, 544–545, 544 patello emoral joint, 499–500, 499 radiocarpal joint, 354–355 subtalar joint, 543–544, 543 temporomandibular joint, 116–117, 117 , 120 transversus abdominis, 382b trauma see injuries treatment adverse responses to, 40 assessment during, 40 clinical standards, 47b–49b intensity, 39b reassessment be ore and a ter, 38–40 selection/ progression, 11, 31t–32t stagnation, 41 stopping, 8–9 see also specif c techniques treatment records, 61 Trendelenburg sign, 394–395 trigeminal nerve, spinal sensory nuclei, 93 trigeminal neuralgia, 96 trochanteric bursitis, 377t–378t, 441t–442t trunk movements, 396 Twomey, Lance, 72
U
ulnar rotation, 262 ultrasound, shoulder pain, 159–160 unconditional regard, 75 understanding, 6 upper limb neural provocation test (ULNPT), 179
V vastus lateralis, 457 vastus medialis obliquus, 457, 468–469 recruitment patterns, 468–469, 470 visceral disorders, and shoulder pain, 176t
W weight bearing, 466–467 tests, 395, 395 wellness, 451 ‘windlass’ mechanism, 515 ‘wise action’, 72 World Con ederation o Physical Therapy (WCPT), 66–67, 143–144 wrist see hand/ wrist
Y yellow ags, 26b, 44t craniomandibular disorders, 96
ulnar deviation, 349–350, 349 ulnar nerve, 263, 339 palpation, 286, 287 tests, 279, 280 active screening, 280
591
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