Functional Manual Therapy for the Lower Quarter · Functional Manual Therapy for the Lower Quarter...

7/19/2013

Jack Miller 1

Functional Manual Therapy for the Lower Quarter

Dr. Jack Miller, Western Univ., London, Canada

Case history #1

• 25 y/o male auto plant worker

• Wanting to train for weight lifting

• C/O upper/mid back symptoms with doing weighted squats

• Wants personal trainer advise on how to strengthen his upper back

• What would you do?

2

Deep squat movement pattern

3

What do you observe?

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Jack Miller 2


5

Case history #2

• 23 year old university student

• 6 months increasing anterior knee pain

• No history of: injury, locking, giving way

• Worse after step aerobic class

• Wants personal trainer to help strengthen quadriceps muscles


6

Hurdle step movement pattern

7


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9

Case history #3

• 50 year old male accountant

• One year history increasing right-sided low back pain

• Described as general ache

• Worse with standing, walking, eased by sitting

• Wants personal trainer to work trunk core muscles


10

In-line lunge movement pattern

11


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13

With each of these cases

Functional movement loss 14

Functional Movement Loss

Tissue extensibility dysfunction

15

Tissue extensibility dysfunction resets

• Muscle shortening

• Trigger point activity

• Scarring and fibrosis

• Neural tissue

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Functional movement loss

Tissue extensibility dysfunction

17

Functional movement loss

Joint mobility dysfunction

18

Joint mobility dysfunction

Obstruction

Mechanical

block

Restriction

Contracted

soft tissue

19

What do you do if pain is the functional barrier?

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Case history #1

0 Right ankle pain 0

3

2

2

Poor control right stance

3 Poor control right ankle stance

2

2

3

3 3

- -

-

-

3

3

3

3

3

-

3

-

-

3

3

16

21

Where’s the dysfunction?

22


Dysfunctional non-painful R stance 23


Dysfunctional non-painful

Dysfunctional painful right

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Analysis

• Dysfunctional and painful right ankle WB dorsiflexion

• Inability to squat due to loss of ankle dorsiflexion

• Mid-thoracic pain with weight lifting secondary to increased trunk flexion

25

Predicting short-term response to thrust and non-thrust manipulation and exercise

in patients post inversion ankle sprain

• Whitman, Cleland, Mintken, Keirns, Bieniek, Albin, Magel, McPoil

• JOSPT, Vol 39, No 3, March 2009

• Step-wise logistic regression to determine the most accurate set of variable for prediction of treatment success

26

Accuracy statistics with 95% CI for individual predictors

Variable Sensitivity

(95% CI)

Specificity

(95% CI)

+ve likelihood ratio

(95% CI)

Post-test

Probability

Worse when

standing

0.75 0.50 1.5 82%

Worse in

evening

0.46 0.75 1.8 84%

Navicular

drop 5.0

mm

0.77 0.48 1.4 81%

Distal tib-fib

joint

hypomobility

0.68 0.62 1.8 84%

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MWM Ankle Dorsi-flexion (NWB)

• Mobilization

• Anterior glide distal tibia, talus fixated

• Movement

• Passive dorsiflexion

• Tips

• Useful in irritable cases

• Treatment plane is oblique med-lat.

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The Initial Effects of a Mulligan’s Mobilization with Movement Technique on

Dorsiflexion and Pain in Sub acute Ankle Sprains

• Collins, N., Teys, P., Vincenzino B. • University of Queensland • Manual Therapy 9 (2004) • Double blind, randomized controlled trial • Incorporated • Repeated measures • Cross over design • Subjects acted as their own control

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Study Subjects

• 16 participants, 8 male, 8 female

• Recruited from: Queensland University sports medicine clinic

• Average age 28.25 yrs (SD 9.33 yrs)

• Grade II lateral ankle sprain

• “Incomplete tear of the ATFL with mild laxity and instability and reduced function”

• Average duration 40 days (SD +/- 24 days)

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Weight bearing ankle dorsi-flexion “lunge” mesurement

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Outcome measures

Mobility function • Weight bearing dorsiflexion range Pain • Pressure pain threshold (PPT)

• Over proximal 1/3 of tibialis anterior muscle belly • Directly distal to the lateral maleolus over the CFL • Directly anterior to the lateral maleolus over the ATFL

• Thermal Pain Threshold (TPT) • Over the proximal 1/3 of tibialis anterior muscle belly • Directly anterior to the lateral maleolus over the ATFL

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Study Results: Dorsiflexion

• MWM Treatment group • A significant interaction treatment

effect demonstrated for the MWM technique P=0.002

• Average increase from 57.27 to 68.93 cm.

• Placebo group • Average increase from 60.17 to

62.07 cm.

• Control group

• Average decrease from 58.29 to 56.42 cm.

0

10

20

30

40

50

60

70

80

Treatment Placebo Control

pre Rx

post Rx

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Study Results: Pain

• Pressure Pain Threshold

• No significant interactive effects demonstrated

• Thermal Pain Threshold

• No significant effects demonstrated

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Study Discussion

“MWM technique to patients with sub-acute lateral ankle sprains produced a significant immediate improvement in dorsiflexion but no initial effect on mechanical or thermal pain threshold”

“Current and previous research findings suggest the predominant mechanism of action for the dorsiflexion MWM technique is most likely mechanical rather that a direct hypoalgesic effect”

35

Talar subluxation

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Initial changes in Posterior Talar Glide and Dorsi flexion of the Ankle After Mobilization with

Movement In Individuals with Recurrent ankle sprain

• JOSPT Vol 36 No 7 July 2006

• Vincenzino B., Branjerdporn M., et. al.

• University of Queensland St. Lucia

• Double –blind randomized crossover study with repeat measures including a no-treatment control condition

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Outcome measures (dependent Variables)

• Posterior Glide • Method described by Denegar (JOSPT, 32: 166-173, 2002)

• Manual glide of talus with firm capsular end-feel • Measurement of tibial angulation measured with

inclinometer at end feel point

• Weight Bearing ankle Dorsi-flexion • Method described by Bennell (AJP 44(3): - 175-80 1998)

• Distance from tip of great toe to wall

• All measures taken prior to and following intervention

• All measures repeated 3 times

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Independent variables

Weight bearing MWM (WB-MWM) • Subject in standing • Mobilization belt produced posterior glide of talus • 10 sec. hold at ERL • 4 repetitions with 20 sec rest between • 4 sets of 4 performed at each treatment session

Non-Weight bearing MWM (NWB-MWM) • Mobilization applied manually, subjects in supine • 10 sec. hold at ERL • 4 sets of 4 performed at each treatment session

No treatment group (control) • Standing in relaxed posture with no manual contact • Same time as per treatment groups

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Results (Posterior glide)

• Significant improvement in:

• Posterior glide range for Rx groups

• WB-MWM produced effect size of 0.8

• NWB-MWM produced effect size of 0.9

• Control produced non-significant effect size of 0.3

• Posterior glide deficit reduced by:

• 50% with NWB-MWM

• 55% with WB-MWM

• Significantly different than control (p=0.003)

• Post-hoc analysis revealed significant pre-to post application for WB-MWM and NWB-MWM

• ( p<0.001)

Posterior Glide (Deg.)

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

WB-MWM NWB-MWM Control

Pre-MWM

Post-MWM

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Results (Dorsi-flexion)

• Changes in dorsiflexion

• WB-MWM and NWB-MWM = 26%

• Control =9%

• Significant (P=0.001) main effect for time (pre – post treatment)

Dorsi-flexion (cm.)

3.8

4

4.2

4.4

4.6

4.8

5

WB-MWM NWB-MWM Control

Pre-MWM

Post-MWM

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Discussion

• Both WB and NWB MWM increased posterior talar glide and talocrural dorsi-flexion

• No major difference between WB-MWM and NWB-MWM outcomes

• Weight bearing is not required to achieve positive results with MWM dorsi-flexion

• Hypothesis of a “positional fault’ of anterior talar resting position is reduced by the application of the MWM procedure

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Anterior talar subluxation

• Delahunt, Medicine Science in Sport, 2013 • Cosby, Athletic Training & Sports Health Care, 2011 • Wikstrom, Archive of Physical Medicine, 2010 • Hoch, J. Sport Rehabilitation, 2010 • Drews, J. Science and Medicine in Sport, 2009 • Landrum J. Manual Manipulative Therapy, 2008 • Reid, Physiotherapy Canada, 2007 • Vincenzino, J. Orthop & Sports Physical Ther 2006 • Hubbard, Physical Therapy in Sport, 2005 • Collins, Manual Therapy, 2004 • Denegar, J. Orthop & Sports Physical Ther, 2002 • Green, Physical Therapy, 2001

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MWM Ankle Dorsi-flexion (WB)

• Mobilization

• Anterior glide distal tibia, talus fixated

• Movement

• Patient lunges forward

• Tips

• Progress from non to partial to full W/B

• Track with dynamic treatment plane

45

Cleland J, Mintken P et. al., JOSPT 2013;43 (7)July:443-455.

Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial

• 74 subjects grade I, II inversion sprain

• No time limits, 3:10 NPRS, -ve Ottawa rules

• Home exercise program only (4 PT visits)

• MTEX + 4 OMT procedures (4 PT visits)

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Functional Ankle Activity Measure

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Lower Extremity Function Scale

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Case history #2

03

03

0

3

2

3

3

3

2

0

-

-

3

3

-

3

3

3

-

3

-

3

3

3

Rotates right leg externally

20

Right ant. knee pain

Right ant. knee pain

49


50


Dysfunctional painful Functional pain free 51


Functional non-painful 52

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Analysis

• Dysfunctional and painful right hip

• Loss of hip internal rotation

• Increased mechanical stress on knee during step ups in aerobic class

53

Altman R. et. al., The American College of Rheumatology criteria for the classification and reporting of osteoarthritis

of the hip, Arthritis and Rheumatology, 1991;34:505-14.

• Cluster one: • Hip internal rotation < 15º • Hip flexion < 115º • Age > 50 years

• Cluster two: • If Hip internal rotation >/= 15º

• Pain with hip internal rotation • Duration of AM stiffness of hip </= 60 min. • Age > 50 years

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Hip internal rotation and knee OA and/or Pain

Knee OA

• Deyle An In Med 2000

• Deyle Phys ther 2005

• Cliborne JOSPT 2004

• Currier JOSPT 2007

Anterior knee pain

• Lowry JOSPT 2008

• Iverson Phys Ther 2008

• Mascal JOSPT 2003

• Cibulka JOSPT 2005

• Vaughn JOSPT 2000

• Powers JOSPT 2000



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CPR Currier JOSPT 2007,

• Hip groin pain or paresthesia

• Anterior thigh pain

• Passive knee flexion <122 degrees

• Pain with hip distraction

• Passive hip internal rotation < 17 degrees.

• +ve LR if 1 variable = 5.1

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CPR Currier JOSPT 2007,

• Hip groin pain or paresthesia

• Anterior thigh pain

• Passive knee flexion <122 degrees

• Pain with hip distraction

• Passive hip internal rotation < 17 degrees.

• +ve LR if 1 variable = 5.1

• +ve LR if 2 variables = 12.9

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Hip Pain and Mobility Deficits Altman R, Delitto A. et. al., 2009, Hip Osteoarthritis:

Clinical Practice Guidelines, JOSPT,;39(4), A1-A25.

• Interventions - Manual Therapy “Clinicians should consider the use of manual therapy procedures to provide short-term pain relief and improve hip mobility and function in patients with mild-hip osteoarthritis.”

• Based on moderate level evidence.

58

Clinical Practice Guidelines

Orthopaedic Section of APTA Cibulka 2009

“Clinicians should consider the use of manual therapy procedures to provide short term relief and improve hip mobility and function in patients with mild hip osteo-arthritis”

American College of Rheumatology Hockberg 2012

“Patients with hip OA should . . . Use manual therapy in combination with exercise under the supervision of a Physical Therapist”

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Hip Internal rotation MWM

Mobilization

• Lateral glide femur

Movement

• Internal hip rotation

Tips

• May need anterior+/-inferior vector

• Control pelvis

• Ensure knee stable

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Netherlands

MCID = 4 POINTS

61 62

63

USA

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Hip internal rotation MWM (closed chain)

Mobilization

• Lateral glide of hip via belt

• Fixate pelvis

Movement

• Internal rotation via patient twisting

Tips

• Control pelvis

• Ensure client is stabilized by holding a chair back or bed

65

Case history #3

2

-

0

3

3

2

-

3

0

3

0

2

-

3

0

1

Right low back pain

+ + Low back pain

1

2

-

1

1

12

1

2

Right low back pain

Hamstring tension

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67

Hip Extension

Dysfunctional and non-painful Dysfunctional and non-painful 68

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Thomas test +/- modifications

Dysfunctional and non-painful Dysfunctional and non-painful 69

Bilateral lumbar extension

Functional and painful Functional and painful 70

Unilateral lumbar extension

Functional and painful (Right) Functional and painful (Right) 71

Analysis

• Functional painful lumbar extension

• Dysfunctional, non-painful loss of hip extension

• Increased stress on lumbar spine related to loss of hip extension in standing / walking

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Jack Miller 19

Hip extension MWM open chain “thomas test”

Mobilization


• on stabilized pelvis

Movement

• Hip extension in Thomas test position

Tips

• Ensure to control pelvic tilt to avoid lumbar extension

73

Loss of hip range of motion and mechanical low back pain

• Freberg O, Spine 1983. • Offierski C, Spine 1983 • Mellin, Spine 1988. • Barbee-Ellison J, Phys Ther 1990. • Chesworth B, Physio Can 1994 • Mellin G, Spine 1998. • Cibulka M, Spine, 1998. • Vad V, J. Sci Med & Sport, 2003 • Warren P, JMMT, 2003 • Vad J Sci Med sport 2003 • Hasseet Arth rhem, 2003 • Sjolie, Scan J Scie2004 • Vad V, AmeJ Sports Med, 2004 • Hoeksma HL Arth Rheum 2004 • Brown ,Clin Orth Res, 2004

• Childs J, Ann Int Med, 2004 • Macdonals, JOSPT, 2006 • Ben-Galin, Spine, 2007 • Wainner JOSPT 2007 • Van Dillen, Arch Phys Med, 2007 • Kirkos, Acta Orth Bel, 2008 • Sembrano, Spine 2009 • Reiman J Sport Rehab 2009 • Murray Phys Ther Sport 2009 • Schottles Clin Biomech 2009 • Van Middelkoop Eu Spine, 2010 • Parviszi Clin Orth Rel Res,2010 • Dagenais J, Spine 2010 • Stupar JMMT 2010 • Burns JMMT 2011

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MWM Hip Extension (closed chain)

Mobilization

• Patient in step/stand


Movement

• Patient lunges forward

Tips

• Control pelvic tilt

• Consider rotation of femur

• Don’t pull patient over

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Backstrom K, Whitman J, Flynn T, 2011, Lumbar spinal stenosis-diagnosis and management of the aging spine, Manual Therapy Masterclass; 2011 Aug;16(4):308-17.

• Patient education

• Aerobic training and exercise

• Manual therapy

• Lumbar spine

• Hip

• Normalization of hip motion appears to be a key element for the successful treatment of patients with LSS

• “The ability to move the hip , especially into extension without concomitant lumbar extension is frequently necessary for pain free ambulation . . . “

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The 2 X 2 function matrix

Non-painful

Painful

Functional FN

FP

Dysfunctional DN

DP

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Non-painful

Painful

Functional Continue with wellness program

Dysfunctional

78


Non-painful

Painful

Functional

Specific motor control training

Dysfunctional

79


Non-painful

Painful

Functional

Dysfunctional Soft tissue resets • Needling • ASTYM • Neural mobilization

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The 2 X 2 matrix

Non-painful

Painful

Functional

Dysfunctional

Functional manual therapy

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Take home message

• Use the SFMA to find the dysfunctional “driver” behind the symptoms

• Tissue extensibility drivers can often be self treated

• Joint mobility deficit drivers may require manual therapy

• Functional manual therapy treats the Dysfunctional / Painful clinical pattern

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Functional manual therapy

• Manual therapy is a safe and effective reset

• Functional manual therapy (FMT) incorporates the symptom provoking activity as treatment

• FMT allows you option a “functional engagement strategy”

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Functional Manual Therapy for the Lower Quarter · Functional Manual Therapy for the Lower Quarter...

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