Joints Treatment MT3

Question 1

what should be treated?

Answer 1

signs and symptoms (info from subj assess and PE) and not diagnosis
1st distinguish the problem stucture ( prim and secondary joint) = differential diagnosis

Question 2

e.g of treatment protocol when the patient has OA of the knee?

Answer 2

NB- dont focus on OA but go back to individual pt in front of you
?main problems?
?what bothering the patient?
?main complaints about condition affecting him?

overall:
what is S&S that pt present with at that moment
might change each session

Question 3

what is the focus of the treatment theme?

Answer 3

treatment of the primary joint structures

by: using manual joint mobilisation i.e moving the joint

Question 4

What are the primary joint structures?

Answer 4

capsules
ligaments
cartilage
articulation surfaces
=present at prim site of joint

treatment process:
mobilise the capsule & associated structures
facilitate the gliding & sliding & rolling of jnt structures

Question 5

in context treatment:

Answer 5

cannot be isolated to joint alone, it will always, to greater or lesser extent, influence muscle/ nerve tissues

(seldom found that only joint structures are affected, therefore attention must be given to all the subsytems of body during the eval- clinical reasoning is very NB)

e.g which struct affected when do AP on fibula head?
popliteal nerve
hamstring
gastrocnemius

Question 6

what is main AIM of mobilisation?

Answer 6

to ensure maximum and painfree function of the NMS system
-within the abilities of the client

you want to get your pt to point where he/she can do what they really want to do (FN is main aim)

Fn goals between people will differ/ between age
=need to change treatment plans according to fn goals

Question 7

treatment based on ICF

Answer 7

1. Impairment
pain, stiffness, spasm
treat these to influence:
2. (Dis) ability/ function
e.g cannot drive car/ cant step up or down
3. participation
e.g cannot perform work or play soccer

so we want to re-edu the fn to influence his participation & facilitate participation= reach max potential for the pt

Question 8

What is the 5 pillars of health care?

Answer 8

prevention 
promotion
treatment
rehabilitation
referral

Question 9

what is the role of joint mobilisation within the 5 pillars of health care?

Answer 9

1. Accurate evaluation
   ID: impairments, disabilities, participation restrictions of specific pt
   1.1 prevention
   assist to find methods to prevent injury or ways to chnage the way the person using the device
   1.2 promotion
   e.g advice pt to lose weight/ ergonomics
   1.3 treatment
   joint mobilisation techniques
   1.4 rehabilitation
   appropriate exercises, to return to everyday activities
   1.5 referral

Question 10

What can be faulty at the joint?

Answer 10

pain
hypomobility
muscle spasm
hypermobility
instability
abnormal resistance
abnormal quality of movement

Question 11

what are the causes of joint abnormality?

Answer 11

capsular stiffness
abnormal biomechanics
pain
muscle spasm
muscle weakness
muscle stiffness
muscle imbalance

pathology (degeneration, inflammation)
cant be treated with MT but can be indirectly treated with MT

Question 12

what are the AIMS of treatment?

Answer 12

to decrease abnormal joint factors (PRS)
to increase joint mobility
to improve tissue fluid dynamics (reduce swelling)
to correct muscle imbalances
to reduce postural stress
aids in functional recovery
to advice and educate

muscle imbalance and postural stress treated?
e.g shoulder and thorax
losen the thorax to provide the R for scapular muscles to re-align T.
the m contract better after the joint has been mobilised by correcting proprioceptive input and optimal jnt position aid in opt correc recruitment of the m surrounding the joint
therefore the scapula m will have improved fn on scapula & aid/ assist shoulder move

Question 13

what do you have in your basket/toolbox to achieve these treatment aims:

Answer 13

EPT
immobilisation
exercise
advice and educate
re-education (HOL)
strengthening 
mobilisation :soft tissue
Mobilisation

techniques chosen specific to individual pt

Question 14

what is manual joint mobilisation?

Answer 14

(he who works with his hands is a laborer; he who works with his hands and his mind is a craftsman; he who works with his hands and his mind and his heart is and artist.

consider the pt and their life & environment & what are your trying to achieve for them

Question 15

what are the different philosophies of joint Rx

Answer 15

1. Maitland

2. Mulligan

Question 16

types of techniques for joint mobilisation:

Answer 16

1. Active movement (assisted or not)
   could be physiological movement =osteokinematic move
   -bone move through range around axis of joint
   e.g Fl, Ext; abd/add & internal/ ext rotation
2. passive movement
   PAM= access/ arthrokinematic- occur at any joint: small movement (roll, glide, slide)
   PPM
3. combination of the above

NB consider the rhythm when applying these techniques

Question 17

what are the types of techniques for joint mobilisation?

Answer 17

active movement (assisted or not)
-mulligan
PAM
-maitland, mulligan
PPM
-maitland, mulligan
combinations of above
-maitland, mulligan

Question 18

the usefulness of PPM

Answer 18

local circulation
joint nutrition
pain relief
ROM= improve and maintenace
Relaxation

e.g
paralysis= have some effects on bone health & contracture at the joint (quadriplegia/ paraplegia)- immobility/ lack of move: soft tissues can start to contract & use PPM to maintain ROM, prevent contraction at joints
diabetes= may develop diabetic neuropathy: nerve damage-> cause dec in ROM in ankle (tighten collagen of soft tissues in this area- painful movements) =PPM: pain relief, improve or maintain ROM
immobilisation in bed (cones callipers)= PPM: maintain joint range, prevent stiffness, help relaxation
joint pain= PPM help with circulation & jnt nutrition & relieve of pain

Question 19

what is the usefulness of PAM

Answer 19

improve joint mobility (ROM)
improve joint play (arthrokinematics)
pain relief
joint nutrition
confirm/ refute joint involvement (Assessment)

e.g
stiff knee post immobilisation (can glide patella to relieve joint pain)
tennis elbow (change grip or strengthen muscles)
cervical pain (facet) - locked or stuck; use PAM
nerve root injuries (targets nerve space/ neural dynamics) ; pain relief

Question 20

usefulness of PAM in more detal:

Answer 20

joint play (arthrokinematics) = if the joint cannot glide effectively, limit jnt ROM; capsule stiff and m weaken
compression of joint surfaces can increase intra articular joint pain: graded compression can be used to treat pain
distraction of joint surfaces can decrease intra articular joint pain: distraction can thus be used as treatment for pain

Question 21

What is the treatment plane of the joint?

Answer 21

is an imaginary line that runs through the joint; parallel with the concave surface & at 90 deg angle to the axis of rotation of the convex surface

NB as it influences your treatment direction/ angle

this means that if the concave surface moves, the treatment plane moves

Question 22

how does the treatment plane influence the treatment direction?

Answer 22

if apply a PAM e.g glide= it will be parallel with the treatment plane

e.g knee= lateral or medial glide

if do compression or distraction= it will be perpendicular to treatment plane

Question 23

why is the concave-convex rule NB?

Answer 23

it influences your choice of technique
choice of technique is dependent on the biomechanics of the joint

direction of the glide:
when the convex surface moves, the direction of the glide is opposite to the direction of the moving lever arm
e.g the treatment plane does not move
because the concave part of joint is not moving

Question 24

convex-concave rule carried on:

Answer 24

If the concave part of the lever arm moves= the direction of the glide within the joint is in the same direction as the moving lever arm

in this e.g
the treatment plane moves, because the concave surface of jnt moves
means that when apply treatment= you will also have to change direction of treatment according to how concave jnt arm is aligned

Question 25

2. why is the concave-convex rule NB?

Answer 25

we use it to work out which glide we should use for treatment by manual mobilizations for treatment, we use the direction of glide that is associate with the problematic movement thus work out which PAM is needed from the restricted physiological movement & then use that glide as 1st choice to treat

Question 26

Knee Fl

Answer 26

the pt can only do 60 deg of knee fl because it is painful therefore we use post glide on tibia to treat it because when doing knee flexion the tibia which is the concave surface moves in a post direction so treat at 60 deg for stiffness by applying a glide

Question 27

shoulder abduction

Answer 27

if painful at 100 deg we use inferior glide on the humeral head, because the moving lever arm is convex

Question 28

MAITLAND key aspects

Answer 28

``` patient centeredness way of thinking- reasoning specific evaluation techniques assessment ```

Question 29

what MAITLAND concept?

Answer 29

not mechanics of technique, But in it's approach to the patient and his particular problem. Attention to detail in exam, treatment and response. concepts/guidelines of assessment and treatment sound foundations of basic biological knowledge the necessity of high level of skill the evolution of the concepts: the necessity for detailed exam and for the exam/ treatment/ re-exam approach

Question 30

evaluation (need a thorough)

Answer 30

subjective (interview) assessment | objective (physical) assessment

Question 31

techniques of MAITLAND

Answer 31

a technique is the brainchild of ingenuity: - dynamic =need to progress as the pt progresses - techniques for Ev vs Rx - adaptation of techniques (can use exam tech as treatment tech when modified) - PAM & PPM as Rx - always evaluate your technique efficacy

Question 32

what is unique to MAITLAND concept?

Answer 32

oscillatory/ repetitive method of technique application rhythm of technique grades of movement compression as treatment technique

Question 33

what does Oscillations: rhythm mean?

Answer 33

reps of same technique= e.g AP glide of tib on femur- should be smooth & uniform, even rhythm slow come up and then down (up & down movement; equal in size; time of each wavelength is the same)

Question 34

rhythm of the techniques?

Answer 34

rhythm can be (slow, fast, sustained) -> smooth, staccato/flicking, broken

Question 35

oscillations: amplitude of technique?

Answer 35

how big the wave is

Question 36

grades of movement?

Answer 36

``` not only decision making tool but also communication tool & determined by: -determining the resistance (R) -the amplitude (A) of the movement performed ```

Question 37

types if passive movement

Answer 37

``` physiological/ accessory or combined -PPM -PPM &PAM -PAM ```

Question 38

when doing MAITLAND treatment

Answer 38

PPM or PAM or combinations grade of movement rhythm of movement with or without compression/ distraction

Question 39

compression vs distraction for Rx

Answer 39

there is a time in Rx when joint surfaces should be kept apart (avoid contact) -> while still being able to Rx by PM to avoid aggravation (e.g. joint very irritable/ SIN/ severe P very small distraction (<1mm) equally (and more commonly) there is a time for moving a joint while compressing the joint surfaces - for 'chronic' symptoms ('chronic' i.t.o current Sx's i.e. not necessarily 'long term' problem) e. g shoulder P where P is provoked by lying on affected shoulder (so the longer before pain starts= the longer the compression force applied)

Question 40

which factors influence your choice of treatment?

Answer 40

1. patient diagnosis (e.g RA, OA, post #) history, stability of the condition, stage of healing symptoms and signs (pain vs spasm vs stiffness) response during/ after treatment

Question 41

what are the phases of conditions of Maitland?

Answer 41

Phase 1: pain and stiffness phase 2: intra-articular, peri-articular phase 3: arthritic conditions phase 4: impacted # phase 5: hypermobility phase 6: loose fragment in joints (e.g meniscus/ cartilage)

Question 42

MAITLAND phase 1:

Answer 42

pain and stiffness -patients with readily recognizable combinations of signs and symptoms can be divided into FOUR main clinical groupings for the purposes of selection and progression of mobilization techniques

Question 43

phase 1 has 4 groups:

Answer 43

group 1: pain group 2: stiffness group 3: 3(a) P>S; 3(b) S>P group 4: momentary pain

Question 44

Group 1: pain dominant factor | movement is limited by pain only

Answer 44

``` key features: pain present with rest pain starts early in ROM pain limits the movement early in ROM if SIN-> take precautions not to cause flare up during Ev and Rx ```

Question 45

Group 2: stiffness

Answer 45

key features: stiffness limits the movement pain be present only at the end of ROM (stretch)

Question 46

Group 3: pain & stiffness occur simultaneously and is related each other

Answer 46

``` key features: pain intensity inc proportional to inc in stiffness (felt as resistance) 3(a) P>S 3(b) S>P joint factors occurs together TROM ```

Question 47

Group 4: pain is dominant, but pain is momentary

Answer 47

key features: no observable dec ROM with general movement pain is associated with certain movements/ positions (only) sudden 'bite/jab' of P-> reproduced with combination movements/ sustained combination movements (quadrant positions)

Question 48

Rx guidelines- group 1: pain

Answer 48

general: NB determine SIN (get from interview) determine P1 or point where pain increases correct positioning of painful joint is imperative too much movement may even lead to pain after stopping the movement (latent pain) Rx needs to be 'gentle' choice of rhythm: slow & smooth

Question 49

what are the group 1 treatment rules?

Answer 49

1. P1< 60% of normal ACTIVE mvmt 2. P>60% of normal ACTIVE mvt 3. P1>75% of normal ACTIVE mvt

Question 50

If, P1 <60% of N act mvt:

Answer 50

Rx in p-painfree position/neutral joint well supported while treat outside (not in) P do only PAM's or shaft rotation (spin) where possible, i.e joints that can spin) choose one direction of movement (as a start) big amplitude movements- Gr2 and progress to Gr 3

Question 51

If, P1>60% of N act mvt:

Answer 51

Rx in a painfree position (but more than neutral) Rx in a painfree ROM (outside of pain) can do PAM's: Gr II or *III can do PPM: Gr II or *III *if possible can start in resistance progress: choose joint position to treat further in ROM

Question 52

P1>75% of N act mvt:

Answer 52

Rx in 10-20% of pain (=in discomfort) Rx near to the EOR can do: PAM: Rx in R (even do GrIII+ or IV+, if indicated) PPM: Rx in R(even do GrIII+ or IV+, if indicated) combination: PAM in a passive physiological position -e.g GH PA in 150 deg fl) therefore bring up arm to 150 deg fl & then a PA glide on GH joint to help with last part of movement

Question 53

dosage for Group 1 conditions:

Answer 53

dosage is time contigent (depend on time) If SIN/ if irritable = 3 sets of 10 sec each (10 sec of oscillations & you will repeat 3 times= more or less 1 oscillation per second) if not SIN =3 sets of 30 sec each more or less 1 oscillation per second re-evaluate after each set

Question 54

Rx Guidelines- group 1: Pain

Answer 54

choice of technique: - choice of direction of glide (PAM) -> acc to biomechanical rule (convex-concave rule) - choose most limited PAM - at later stages-> progress to most painful PAM

Question 55

Rx Guidelines - Group 1: Pain | where in the ROM should I do the moblisation?

Answer 55

If SIN or if irritable- perform the technique far away from P1 if pain increases quickly with movement- perform the technique far away from P1 e.g: Act Sh F (L)= 0-60 deg (8/10 pain) treat in neutral or 10 deg of fl

Question 56

Rx Guidelines- Group 1: Pain | what amplitude should I choose?

Answer 56

where in the ROM P starts how P inc (behaviour) irritability But in practice... "the larger the amplitude that can be performed when treating pain, the more effective it will be" - SIN or irritable condition= small A - when you mobilise closer to P1= small A - when you mobilise further from P1= large A

Question 57

Re-evaluation | How do you know that the pain (group 1) improved?

Answer 57

1. Pain occurs later in ROM that before 2. pain intensity dec (8/10 -> 7/10) 3. speed with which pain increases is slower (dec) so that they can do more move before the pain starts then you will know pain improved & techniques are working

Question 58

Re-evaluation | How do I adapt my technique after re-evaluation?

Answer 58

``` If Sx are better -repeat same procedure -progress to bigger A -progress to deeper in R If Sx are worse -decrease A (smaller) -decrease ROM (do earlier in ROM) No change -repeat procedure -or try another technique ```

Question 59

Rx guideline- Group 2: Stiffness

Answer 59

General: mobilise needed @ point of limitation in all indicated directions any PPM and all PAM that is limited may be used in EOR of physiological movements as stretching techniques

Question 60

Rx Guidelines- Group 2: stiffness

Answer 60

Option 1: identify limited physiological movement take to EOR whilst keeping joint @ limit, use PAM as stretch technique perform small amplitude oscillatory stretching movements (GrIV+/GrIV ++) choose PAM acc to biomechanics

Question 61

Rx Guidelines- Group 2: stiffness | Option 2

Answer 61

``` identify limited physiological movement take it to EOR perform small amplitude oscillatory stretching movements (Gr IV+/GrIV++) smooth or staccato rhythm you are using the PPM as Rx treatment ```

Question 62

Rx Guidelines- group 2: stiffness (dosage)

Answer 62

dosage= 4x60 sec OR 4x45 sec (stretch the capsule)

Question 63

Rx Guidelines- Group 2: stiffness | aftercare of joint after stretching it

Answer 63

``` treatment pain (Rx P) common due to stretching of structures ``` ``` how to treat Rx pain? PPM in direction you stretched in gr III or Gr III- 30sec x 3 oscillations =to get rid of the pain metabolites can apply heat for the pain/ EPT ```

Question 64

Group 3: Pain & Stiffness

Answer 64

determine which is dominant: pain or stiffness | determine the exact relationship between stiffness and pain (movement diagram)

Question 65

Group 3(a): Pain > Stiffness

Answer 65

``` general: the movement is limited by pain But there are some underlying stiffness Usually not SIN therefore can treat in R Rx and progress with group 1 (pain) treatment direction of movement need to correlate with functional problem ``` BUT dosage= 3x30 sec if no change in Sx: try active mobilisation (e.g Mulligan) OR Rx as Group 3(b) but consider pain- just touch on pain

Question 66

Group 3(b) : Stiffness > Pain

Answer 66

treat almost like for Group 2 stiffness limits the movement, but there is pain not associated with stretching the tissues ``` treat 5-10 degrees short of EOR within R (always GrIII or IV) (and - or +) Rx focussed on addressing R Respect pain: can touch P1- but don't go into it dosage: 30 sec x 3 ```

Question 67

Group 3(b): Stiffness > Pain

Answer 67

progression: when pain decreases- move further into ROM may need to treat: Rx Pain muscle spasm

Question 68

``` Group 3(b): Stiffness > Pain what if there is muscle spasm? ```

Answer 68

1. evaluate: joint well supported? your handgrips correct and firm 2. dont force through spasm do small A PPM against the spasm (can try with PAM also) try to move further in ROM 3. Can use continuous stretch (stretch out the muscle in spasm)

Question 69

Group 4: momentary Pain

Answer 69

must get a positive * sign (i.e must reproduce the pain) usually a combination movement (e.g Quadrant) can be a sustained position with compression (kneeling) Rx: use the combination movement that reproduced the symptoms (e.g knee fl/ add) use Gr IV and Gr III (tot ++) (vary between the two grades)

Question 70

Group 4: momentary | Dosage

Answer 70

1 x 60 sec In pain treat for treatment pain