Purpose

1. Purpose To consolidate and expand your knowledge and skills of Manual Therapy

2. Objectives • Canadian Manual Therapy history • Subjective examination • Objective examination –lumbar, pelvis , hip,cervical , TMJ, • Treatment approaches including mobilizations, exercise, education and manipulation

3. Definition of Manual Therapy A comprehensive system of diagnosing and treating neuromusculoskeletal disorders involving specific skills, including assessment, mobilization, manipulation and education, in conjunction with exercise, to restore optimal motion, function and/or reduce pain. MTSC Vision 2001

4. Clinical Reasoning Hear See Feel Biomedical Knowledge Clinical Knowledge – knowledge, skill experience

5. Clinical Reasoning • The process of drawing conclusions based upon known or presumed facts • Development of an accurate diagnosis and prognosis

6. Hypothesis Generation • Data collection • Interpretation of information • Cross-examination • Contributing factors • Hypothesis modification • Treatment • Reassessment • Prognosis

7. Beginner • Systematic approach • Gather as much information until diagnosis emerges • Check list may be helpful • Takes longer to recognize clinical patterns Level 1 pg 4

8. Novice • Repertoire of clinical patterns • Abandon checklist • Lack experience to identify all clinical patterns • Often tempted to make assumption

9. Expert • Need a superior knowledge base from which to generate a high quality hypothesis • Clinical patterns

10. What qualities define a clinical specialist? content knowledge practical knowledge technical skill application of general principles or theory critical analysis Mildonis et al, JOSPT, 1999

11. Expert • Intense focused connection with patient, verbal and non • Use clinical patterns and inductive reasoning to develop a diagnosis • Comfortable with the uncertainty of not knowing the immediate diagnosis

12. Expert • Management becomes more efficient and effective • “ seeing” the clinical pattern • Allows PT to focus on 1 or 2 primary issues • Recognize what features are most significant and in need of attention

13. Former Paradigm • Unsystematic observations OK • Knowing basics OK • Common sense enough • Clinical experience enough

14. The Danger of Relying on Experience Alone “making the same mistakes with increasing confidence over an impressive number of years.” M. O’Donnell. A Skeptic's Medical Dictionary Is that 25-years of experience or 1-year of experience repeated 25-times?

15. New Paradigm • Intuition- misleading • Rationale for treatment and discharge may be incorrect • Understanding rules to interpret the literature is necessary

16. Why Evidence- based Practice • 30,000 biomedical journal articles per year with a 7% increase each year • There are over 3,200 physiotherapy articles published per year • To keep up to date, a clinician would need to read approximately 10 articles per day • If 2 articles are read per day, after 1 year a clinician would be approximately 4 years behind

17. Consequences of Not Keeping Up-To-Date • Lag in optimal practice behaviors • Clinical practice is opinion driven • Patients may be denied best care • Patients may selectively know more than clinicians

18. Evidence-based Practice “the integration of best research evidence with clinical expertise and patient values” D.L. Sackett et al, 2000

19. Definition of Manual Therapy A comprehensive system of diagnosing and treating neuromusculoskeletal disorders involving specific skills, including assessment, mobilization, manipulation and education, in conjunction with exercise, to restore optimal motion, function and/or reduce pain. MTSC Vision 2001

20. Aim of Manual Therapy • Pain relief • Restoration or improvement of function • Restoration of an acceptable predetermined level of physical lifestyle • Prevention of further episodes • Education, communication , documentation

21. Homeostasis Restoration of normal repair processes facilitated and pain is alleviated

22. Diagnosis • Is physical treatment a treatment of choice? • If so, what type of physical treatment should be used? • Manual Therapy must be based upon diagnostics rather than signs and symptoms

23. Scope of Manual Therapy • Mobilization, Traction, Manipulation • Muscle Energy, PNF • Dynamic soft tissue release • Muscles rebalancing, muscles co-contraction • Stabilization, Exercise Therapy • Functional Rehabilitation

24. Cyriax • Principle – “ search for physical signs , positive and negative and their interpretation” • Selective tissue tension testing • Contractile • Inert

25. Subjective Assessment Why is it SO Important?

26. List the negatives of a history from the patient’s point of view List the positives from a patient’s point of view What are your goals when starting a subjective assessment?

27. The Art of Listening “ We are in danger of overlooking the simple psychological potency of giving patients a good hearing, listening attentively, giving them the benefit of the doubt , handling them with confidence and skill and simply striving to do our shop floor clinical work with effectiveness. Failure to properly examine the patient may lead to unnecessary mischief.” ……..Grieve 1991

28. Listening is an ART: • That is where it differs from hearing • Hearing is passive • Listening is active • Hearing is involuntary • Listening demands attention • Hearing is natural • Listening is an acquired discipline ( the Age ’82)

29. Use our communication skill to help patient understand…… • What manual therapy is all about • What it can do for them • What the treatment will entail • What are their options • What part they play in recovery and treatment • What part they play to maintain their acquired healthy state A Moore + G Jull Manual Therapy 2001

30. Assessment • Subjective History • Objective - observation - active – passive- resisted • Interpretation of Evaluation • Capsular pattern • Resisted findings

31. Treatment • Transverse frictions • Stretch • Manipulation • Injections

32. Lower Quadrant Scan • Rule out serious pathology • Isolate area of dysfunction • Identify others areas in the body that may need attention

33. Observation • Postural type • Gross deformities • Gait

34. Clearing Tests • Squat • Twist • Walk (on heels and toes)

35. Active movements – OP if not painful • Lumbar Spine flexion, extension, side flexion and rotation • Hip flexion, extension, rotation, abduction • Knee flexion, extension • Ankle dorsi, plantar, inversion, eversion

36. Myotomes • L1-2 hip flexion • L3 Knee extension • L4 Ankle dorsiflexion • L5 Gt toe extension, hip abduction • S1 PF ankle, eversion , knee flexion • S2 Hip extension

37. Dermatomes • Light touch – cotton ball, kleenex • Sharp- dull – acupuncture needle, paper clip

38. S2 L5 L4 Sensory Testing Lower Quadrant Hoppenfeld’76

39. Reflexes Achilles - S1 Quad - L3 Hamstrings - L5

40. Pathological Reflexes Neg Clonus Pos Babinski

41. Dural • SLR • Slump • Prone knee bend

42. Articular • SI stress test – anterior , posterior • PA’s lumbar spine – spring tests

43. Perform a lower quadrant scan

44. Kaltenborn • Subjective • Objective • Cyriax • Plus accessory movements

46. Treatment • Hyper • Hypo • Restore normal glide • Arthrokinematics – decrease capsular tightness

47. Maitland Concept Open mind Mental agility Mental discipline Logical Methodical process of assessing cause and effect Link with

48. Assessment Subjective Provides guidelines Pain patterns Objective Priorize assessment Active, passive, pain, resistance Accessory movements Salient signs Quadrants Movement diagrams

49. Treatment • Interpretation of evaluation • Grading • Techniques • Reassess

50. Maitland “ When trying to improve the quality of the sick joint’s movement by a passive movement technique it is necessary to put your mind inside the joint area and involve yourself emotionally with what the joint is trying to tell you”