Principles of MSK Management - notes by 2nd year physiotherapy student PDF

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Summary

Types of flags, manual therapy, mobilisation, grading, soft tissue mobs....

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Principles of musculoskeletal management International classification of functioning, disability & health model

Domains of international classification of function - Body function and structure - impairment (strategy - MT)! - Activities - capacity and/or performance (intervention) ! - Participation - barriers and/or facilitators (rehab programme, increased physical activity)! Manual therapy (Musculoskeletal toolbox) - Manual physical therapists possess a variety of tools (skills) in their toolbox! - The art of manual therapy is knowing which tools will work best for the patient sitting in front of us! - There is evidence that including manual therapy care as part of the conservative management of patients with musculoskeletal conditions results in cost effective improvements in pain, function and satisfaction!

Musculoskeletal management toolbox Patients safety - contraindications! - In determining objective assessments and management/treatment we need to consider all precautions and contraindications! - As this applies a limit to what treatments and management may or may not be possible!

Types of flags (adapted from petty & Ryder 2018)

Precautions to spinal and peripheral MT

What is manual therapy? “Skilled hand movements and skilled passive movement of joints/soft tissue intended to improve tissue extensibility, increase range of movement, induce relaxation, mobilise or manipulate soft tissue and/or joints, modulate pain, reduce soft tissue swelling, inflammation or restriction.” (American Physical Therapy Association, 2014)! Desired effect of a joint mobilisation * Create an efferent barrage to initiate a neurophysiological response to reduce pain! * Glide joint surface parallel to plane of joint or rotate joint surfaces! * Move joints surfaces to lengthen periarticular tissues!

* Move joint to affect nerve or muscle tissue! * Encourage normal patterns of movement! * Reduce fear of movement! How do mobilisations work? - Psychological mechanisms! - Biomechanical mechanisms! - Neurophysiological mechanisms (peripheral, spinal, supraspinal)! How does manual therapy work? Psychological! * Placebo response - ‘laying of hands’, ‘learned/general expectancy’, ‘therapeutic touch’! * Explained positive benefits/evidence base of intervention! * Contextual factors; environment, clinical! Biomechanical! * Alter tissue movement and extensibility (creep and progressive loading)! * Alteration of fluid dynamics! * Promote tissue repair and remodelling! Physiological! * Decreased spinal & cortical excitability! * Inhibit muscle spasm! * Change intra-articular and periarticular pressure! * Decreased response to nociceptive stimuli! * Influences motor control & proprioception! * Anti-inflammatory effect via increased substance P and pro inflammatory cytokines! Connective tissue (Threkeld, 1992) Improve extensibility and tissue strength! Dosage required for this?! - Force varies! - Velocities and accelerations! - Direction and anatomical sites! - Type underlying pathology! - Somatotypes patient! - Somatotypes therapist! Different approaches and schools of thought to manual therapy - There are several different main stream approaches to manual therapy! Maitland Mobilisations! Described the three main purposes of mobilisations capable of:! 1. Restoring structures within a joint to their normal positions or pain-free positions so as to allow as full range of painless movement! 2. Stretching a stiff painless joint to restore range! 3. The relieving of pain! Key Maitland terms! * Accessory movement - Accessory or joint play movements are joints movements which cannot be performed by the individual. These movements include roll, spin and slide which accompany physiological movements of a joint. The accessory movements are examined passively to assess range and symptom response!

* Physiological movement - the movements which can be achieved and performed actively by a person and can be analysed for quality and symptom response! * Injuring movement - making the pain/symptoms ‘come on’ by moving the joint in a direction during the clinical assessment! Overpressure - each joint has a passive range of movement which exceeds its available active * range. To achieve this range a stretch is applied to the end of normal passive movement. This range nearly always has a degree of discomfort. ! McKenzie mechanical diagnosis and treatment (MDT)! - What is it? Repeated movement! - Mechanical subgrouping - derangement/dysfunctional or postural! - Other - postural correction, repeated movements predominantly sagittal (10 repeats 4-5 x), side-gliding (lateral deformity)! - Limitations - not everyone will fit a category so what about “other”, impact of fear of movement * issues with design mitigated as does not account for complex biopsychosocial aspects! Mobilisations with movement (MWMS)! Also known as a Mulligan approach, named after Brian Mulligan! What is it?! - It is an active psychological movement with accessory movement! - As the patient performs an active physiological movement, the therapist can apply an accessory movement (MWM) to a peripheral joint or a sustained natural apophyseal glide (SNAG) to the spine! - A useful intervention which can be included in HEP! Grading - Can be applied to physiological or accessory movements (predominantly III and IV’s for accessory movements)! - Communication tool (poor reliability)! - Help you to think about what is happening under your fingers/hands! - Useful in recording treatment! Grades of passive movement Maitland grades I-V! - Grades are defined by two parameters! - The relationship of the passive movement to resistance! - The amplitude of the movement!

Grades 1. Grade I - a small amplitude movement performed at the beginning of range out of resistance! 2. Grade II - a large amplitude movement in a resistance free part of the range! 3. Grade III - a large amplitude movement performed into resistance! 4. Grade IV - a small amplitude movement performed into resistance! 5. Grade V - manipulation (high velocity thrust)!

- Grade III- and grade IV- - movement taken just into resistance! - Grade III+ and grade IV+ - movement taken to end of resistance, i.e. end of available joint range! - Evidence suggests that we are not that good at identifying the start of resistance! Application of mobilisation - The starting position - of the patient and the therapist to make the treatment effective and comfortable and maintains patient’s dignity. This also involves thinking about how the forces from the therapists hands will be placed to have a localised effect or if local tenderness affects the efficacy of hands golds and therefore desired effect.! - Consent and explanation at all stages, don’t forget to ask for symptom baseline pre-techniques and response during and after on reassessment. Know your SIN (severity, irritability, nature) factor ! - The desired effect - what effect of the mobilisation is the therapist wanting? Relieve pain or stretch stiffness? Should the patient be pain-free, have an increased range or have reduced soreness! - Choice of technique - Physiological/accessory! - The method of application - the position, range, amplitude, rhythm and duration of the technique! - The direction - of the mobilisation needs to be clinically reasoned by the therapist and needs to be appropriate for the diagnosis made. Not all directions will be effective for any dysfunction. Think about SMP! - How might the technique be progressed - duration, frequency or rhythm?! - If desired response is not achieved how the technique can be modified or regressed! - Reassessment of asterisked subjective and objective markers! - Outcome measures! Different types of soft tissue mobilisations

- Soft tissue therapies are mechanical forms of therapy where soft-tissue structures are pressed -

and kneeled, using physical contact with the hand or a mechanical device (Australian Acute Musculoskeletal Guidelines Group, 2004)! More than 80 types of soft-tissue therapy exist, some names are:! - Deep transverse frictions! - Myofascial release! - Trigger point therapy! - Foam rolling...