2c - HVT Manip Flashcards by Jenn Cantilli

what is a thrust joint manipulation (TJM)

high velocity, low amp therapeutic mvmt w/i or at end ROM
- w/i normal anatomical range

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what is the significance of Freddy Kaltenborn’s nordic approach to manips in 1961

first to relate manip to arthrokinematics

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what were Geoffrey Maitland’s significant contributions to PT manips

treats “reproducible signs”
oscillatory techniques
- grades I-V

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what were James Cyriax significant contributions to PT manips

clinical reasoning and diagnostic system

he focused on transverse friction massage

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what is the goal of TJMs in PT

reduce pain and restore motion as part of a comprehensive multimodal POC

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what profession has a similar procedure to PT and what profession has a varying procedure

osteopath

chiropractor

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describe when PT hit most of its legislative challenges w manips and why

1990s
PT profession mvmt toward direct access and doctoral ed

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how long has manip been part of PT’s practice and why is this relevant

since inception of profession
vital part of scope of PT

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what is the role that state licensing play in PT manips

in place to assure PTs practice w/i scope of practice and protect the public
-> thrust and non-thrust manips included in NPTE

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what are the 3 components to a PT’s scope of practice

professional
jurisdictional (legal)
personal

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what is the significance of state practice acts and TJMs in PT

have to check state practice rights to see if allowed to do a TJM per legal guidelines
- some states need a MD referral for a PT manip

a lot of practice acts are silent, if don’t list it as prohibited, then implied we can do it

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what state is spinal TJM by PTs prohibited

arkansas

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what is the APTA’s guidance on TJMs

spinal and peripheral joint mobs/manips only to be performed by PT

bc these are considered interventions which require immediate and cont exam and eval throughout intervention

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how can adverse reactions to TJMs be avoided

appropriate screening

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adverse reactions/events to TJMs vs side effects (& ex)

adverse reactions are sequelae that are:
- med to long term duration
- mod to severe sx
- serious, distressing, and unacceptable to pt

side effects:
- short term, mild in nature
- non serious
- transient, reversible
ex: inc neck pain, HA, fatigue

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what is the most common type of adverse event from a cspine TJM? what are specific examples?

neurovascular injury
- cervical a. dissection
- vertebral a. dissection

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positive findings for VBI

5D’s And 3N’s
Diplopia
Dizziness
Dysarthria
Dysphagia
Drop attack
Ataxia of gait
Numbness
Nausea
Nystagmus

concentration problems
metallic taste
tinnitus
unconsciousness
hemiparesis/hemiplegia
(+) CN signs

sudden onset of severe neck pain/HA

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who are cervical/vertebral dissecting vs non-dissecting more common in

dissecting
- young pt w trauma

non-dissecting
- older pts w CV risk factors

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what is the key point if you are trying to do a physical exam for a cervical vascular disorder

there isn’t a single test that can screen for them
- and they have moved away from positional testing

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how is the decision made for implementing a manipulation on the pt

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shared decision making
- is pt comfortable?

is there a greater benefit than the risks
- risk is often low
- higher risk from NSAID use, injections, surgeries

what are 6 adverse events/complications from thoracic/lumbar spine manip

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cauda equina syndrome
SCI
lumbar pedicle fx
lumbar/thoracic compression fx
rib fx
lumbar/thoracic disc herniation

what is cauda equina syndrome

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bilateral sciatica

severe or progressive bilateral neurological deficit of legs

what are s/sx of cauda equina syndrome

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major motor weakness w knee ext, ankle eversion, foot DF
saddle anesthesia/paresthesia
laxity of anal sphincter

difficulty initiation micturition, impaired sensation of urinary flow
-> untreated can lead to irreversible urinary retention w overflow urinary incontinence

loss of sensation of rectal fullness
-> untreated can lead to irreversible fecal incontinence

what is a consideration of TJM technique and the risk of a fx

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unlikely to cause a fx w a small amp thrust
- if too large amp then could cause a fx

what are red flags to screen for prior to a TJM

significant trauma wt loss hx of cancer fever IV drug use steroid use pt >50yo severe, unremitting night pain pain worse w lying down

what are 4 general types of absolute contraindications for TJMs (and examples)

bony issues - any path that may lead to a bony compromise - tumor, infection - inflammatory, trauma neuro issues - any path impacting the neuro system - myelopathy, SC compression - nerve root compression w inc neuro deficits - sudden n/v & vertigo vascular issues - any path may lead to vascular compromise (more for cspine) - VBI, aortic aneurysm, angina - acute ab pain w guarding (AAA) - bleeding diatheses (hemophilia, anticoags) clinical issues - any matter that inc risk of harm to pt - lack of subj/obj exam info - lack of dx - lack of PT skill - lack of pt consent

what are ex of relative precautions for TJMs to thoracic spine

HTN serious degen joint dz growing children serious kyphosis/scoliosis herpes zoster on spine vertigo systemic infection psych dependence on manip pain w psych no change/worse sx after multiple manips

what is the general consensus for safety w thoracic and lumbar TJM and what does the literature say for safety

impossible to determine precise risk - no accepted standard reporting - not all events published clinical decision making based on exam and evidence-based approach

what does the research/CPGs say for TJM use

recommended in CPGs for acute and chronic LBP

what pts w LBP is the evidence not as strong for TJMs and what is the assumption

those w back pain and leg pain - consider neuro involvement anyway

what does the evidence say about manip vs mob in chronic LBP

manip appears to produce larger effect than mob

what are considerations for sidelying lumbar manip

rotate upper body all the way down to level you want to manip and flex leg up to that level short lever arm w arm on pelvis

what is a consideration of supine lumbar regional manip

very non-specific - can have manip anywhere from lumbar to SIJ

what is the lumbar spine clinical prediction rule and what are the

classifies pts w LBP who demonstrate respond favorably to HVT (4 of 5 signs) 1. duration of sx <16days 2. no sx distal to knee 3. LB hypomobility 4. at least 1 hip >35deg IR 5. FABQ work subscale <19pts

what are inclusion/exclusion criteria for lumbar HVT

18-60yo red flags for manip - OP, fx, CA, prolonged steroid use, RA, infection - LMN involvement - pregnancy - prior lumbar surgery

what are the 2 most important factors of the lumbar spine clinical prediction rule

duration <16 days not having sx distal to knee

CPGs recommend thoracic manip in:

pts w neck pain with: - mobility deficits - chronic HA - chronic radiation pain

what do the CPGs say about thoracic manual therapy benefits depending on phase of recovery of neck pain

tends to be better in acute phase - in subacute to chronic stage, benefit tends to dec

what do CPGs say about thoracic manip vs mobilization in neck pain

thoracic manip may not offer any benefit over mobilization (and may be associated w temporary discomfort)

what is an important consideration for your set up with a supine segmental AP thoracic thrust technique

position their elbows under your xiphoid so you can get force from legs and be more effective - bc you are going to be smaller than most pts

what is the overall consensus of what evidence is available for spinal HVTs

greater evidence available for it than other PT interventions evidence for thrust manip for LBP - clinical prediction rule may be of limited help to guide decision making in use of TJM for pts w LBP evidence for mob/manip combined w exercise in neck pain benefit to treating the thoracic spine

what is the proposed mechanical MOA for thoracic and lumbar spinal thrust techniques

realignment breakdown of adhesions dec acute joint locking - meniscoid entrapment joint cavitation - audible click

what is the proposed neurophysiological MOA for thoracic and lumbar spinal thrust techniques

inc firing of mechanoreceptors - inhibition of ms reflex contraction - dec pain perception stim of pain inhibition pathways - PAG

how does manual therapy work per the mechanical and neurophysiological model

1. mechanical force 2. cascade of neurophys response (peripheral and central nervous system) 3. clinical outcomes

how does the patient-provider interaction impact the outcome

a lack of confidence when PT does the technique can create less optimal outcomes

what are 5 indications for a HVT manip

1. hypomobile segment 2. acute facet joint locking 3. mob technique showed benefit but didn't achieve full effects 4. criteria for clinical prediction rule -> L spine 5. neck/shoulder dysfunction -> tspine TJM

what are important components of informed consent

explain nature, purpose, implications, risks, and alternatives for technique document consent every time

what are the steps to the thrust manip technique

1. isolate joint 2. preposition, hold, reposition 3. speed not force** 4. re-assess

what are components to document about the HVT manip

pt position direction of force target/location of force grade of manip

2c - HVT Manip Flashcards

(49 cards)