How to Make Manual Therapy -...
Transcript of How to Make Manual Therapy -...
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How to Make Manual Therapy Functional
Title :Manual Therapy of Adult Knee ConditionsJohn O’Halloran PT,DPT,OCS,CertMDT, ATC,CSCS
O’Halloran Rehabilitation and O’Halloran Consulting LLC
Cross Country EducationLeading the Way in Continuing Education and Professional Development.
www.CrossCountryEducation.com
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MANUAL THERAPY
• 96% Irish Physio’s
• 64% UK
• Employ Manual Therapy in their interventions with knee OA patients‐ ref:Walsh 2009 and Deyle
2005
Manual Therapy
• Joint Mobilization
• Joint Manipulation
• Soft Tissue Mobilization
• Applied at various angles, speeds and often passive and at the end ranges‐ Ref:French 2007
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Manual Therapy : Future(CPR’s)
• Development of a clinical predication rule to identify patients with knee pain and clinical evidence of knee OA who demonstrated a favorable short‐term response to hip mobilization‐Currier LL et al
• Ref:Physical Therapy Journal 87 (9) pp 1106‐1119,2007
Knee caught in the middle
www.ericwongmma.com
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Reviewed the literature, hand journal searches, internet searches combined with
clinical experience
News Reporter
• EBM:
• AHRQ‐Agency for Healthcare Research and Quality‐practical ? : Results of studies focused on single interventions effectiveness vscombinations of RX
• Medicare Prescription Drug Improvement and Modernization Act of 2003
• 405 retrieved therapeutic references
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Osteoarthritis
• Pain
• Stiffness
• Swelling
• Joint instability
• Muscle weakness
Osteoarthrits Treatment‐effectiveness‐agency for health care
• Education/Self Management ‐B
• Impact Loading Execises‐C
• Low Impact Exercises( open chain) –A
• Flexibility Exercises‐C
• Quadricep Strengthening‐B
• Patella Taping‐B
• Bracing‐Inconclusive(unloader brace vs sleeve)
• Foot Orthotics‐B
Pharmacologic Therapy
• Non opioid analgesics‐ B
• Nsaids‐B
• Topical analgesics‐B
• Injections‐B
• Opioid analgesics‐B
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Growing body of evidence
• Therapy’s role in management of adult conditions
• And that role is a MULTIMODAL approach
INTERVENTION GOAL
• The goal with all the various forms of interventions is to SLOW the progression of the disease process
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The older I get the better I was..
• Normal weight at age 18 and obese by age 45 greater chance of developing knee arthritis
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Canadian Joint Registry ‐87% TKA and 74% THA
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Subjective Exam
• Identify:
– severity
– irritability
–nature of the problem.
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Examination Format
• Weight Bearing is preferred
• Postural clues‐General
• Gait
• “Show me what hurts”
• Transitional movements‐exposes the compensation
• Conventional Exam Methods etc
Traditional VS. Functional Exam Summary
• Anatomic individuality
• Tissue DX
• NWB Exam
• Tests look at a specific tissue
• Pain, swelling, ROM Etc.
• Functional
• Patient as a whole Wt Bearing
• Tests look at Multi‐joint/angles
• Balance, Control Etc.
• Healing of the injured plane or movement Structure
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• The integrated functional approach examination will allow you to develop sound clinical reasoning on where the dysfunction is…………..
• Remember it is not the tissue or tendons fault in these cases it is just the part of the body that is screaming at you
Examination‐Lower Extremity
• In everyday life we function multi‐angle with multi contraction types. However our eval’sare still stuck in the saggital plane
• Ex: Supine Exam‐try to get you patients up as much as possible and become a better observational examiner of dysfunction
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What plane of movement do most injuries occur in?
“He who treats the site of pain is often lost” Renowned Czech Physician Carel
Lewit MD
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Assessment is the KEY!!
• “Don’t try to FIX your patient day one…try to understand it first then fix it later” ColinDavies PT Dip MDT
• “I don’t fix people, I assess them until they get better” Mark Miller PT Dip MDT
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Stand up‐examples of kinetic link
So let’s get going and start the thinking process……..
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Arthritis‐some more facts and figures
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Facts and Figures
• Arthritis affects over 70 million in the USA
• It is secondary to Heart Disease in causing disability
• About 1 million new patients per year are diagnosed with arthritis
• 21 million over age 45
• 50% of the 65 and over crowd are affected by arthritis
• Virtually everyone over 75
• KNEE JOINT IS THE NUMBER ONE JOINT AFFECTED
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Research
82% Cadavers over the age of 60 had DJD of the Glenohumeral joint(peterson 1983)
60 % Of Knee Replacements –females
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Factors that affect arthritis
• Previous injury and cartilage breakdown
• Weight
• Age
• Hereditary
• RA
• Septic Arthritis after infection
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Generally accepted Orthopedic treatment of arthritis
• Initially start conservatively…
• NSAIDS ,Weight loss, PRE’s (Swank 2011) , PT, Unload the joint ,water therapy
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Viscosupplementation
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Cochrane Systematic Review 2010
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Viscosupplementation ‐Cochrane Review
• 5‐13 week post injection‐11‐54%
less pain ‐9‐15% better function
20% dramatic improvement
If those measures do not get the desired result…..
Steroid injectionsCochrane Systematic
Review 2010
Joint Arthroscopy-ref 2008 New Eng J Med
Then Joint Replacement Surgery…..
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Let’s Take a Look at Interventions WEDO!!!!!…..
• Insoles
• Taping
• Bracing
• Exercise
• MANUAL THERAPY
• A Combination of therapeutics??
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INSOLES/WEDGES:5‐10 deg wedge decreases 4‐12% mechanical stress‐
butler et al; hinmam et al
Lesher et al. (2006)
Lan et al. (2010)
Patellar Taping
Med.yale.edu
Draganich et al
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Bracing works if compliant
• 50% of patients stop using brace after 6 months‐ ref:ramsey et al; giori et al
• Not as effective in a obese patient‐ ref:dennis et al
Hassan , Kirkey , Pajareya
ORTHOTICS
• Pic of insoles
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Five Finger Shoes‐More Flex=reduced load‐ref:kerrigan
UMASS Study
Cornerstone of Treatment for OA is………
• Exercise has similar effects as NSAID’s and simple analgesics but less contraindications and side effects
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• No particular exercise more effective than another –ref :Pelland
Core and Hips
• Hip strengthening
• Hip exercises can be effective for knee pain when specific exercises cause pain in the knee
PT vs HEP
• PRE’s : THERAPIST SUPERVISON MAY IMPROVE OUTCOME –REF: Frassan , McCarthy
• 2‐3 x/wk x 8‐12 weeks‐ref : Roddy
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Research
• Very supportive on exercise combined with manual therapy‐MULTIMODAL Approach
• Clinical guidelines 2009
• Cochrane reviews 2008
MANUAL THERAPY
Systematic reviews
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Manual Therapy
• Strength training alone vs. exercise alone vs. exercise and passive manual therapy with knee osteoarthritis‐A systematic review‐ref:Jansen MJ et al
• Journal of Physiotherapy 57 (1) pp 11‐20, 2011
Manual Therapy‐Intervention at impairments above and below knee
• Effectiveness of manual therapy and exercise in osteoarthritis of the knee‐Deyle et al
• Self report of function better, 6 minute walk test better after 8 treatments in 4 weeks
• Annuals Internal Medicine 132 pp 173‐181, 2000
Manual Therapy
• Manual Therapy of the hip or knee‐A systematic review‐French et al
• Manual Therapy vol 16 (2) pp 109‐117, 2011
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Manual Therapy
• Six Sessions of manual therapy increased knee flexion and improved activity in people with anterior knee pain: a randomized controlled trial‐ ref:van den Dolder P et al
• Improved stair climbing ability and increased knee flexion ROM vs. control group
• Australian Journal of Physiotherapy 52 (4) pp 261‐264, 2006
Manual Therapy
• The Effects of Manual Therapy on Balance and Falls: A Systematic Review‐HOLT et al
• Journal of Manipulative and Physiological Therapeutics vol 35 (3) pp 227‐234 , 2012
Manual Therapy
• Patellofemoral pain syndrome managed by ischemic compression to the trigger points located in the peri‐patella and retro‐patella areas: a randomized clinical trial‐ ref:Hains G et al
• Clinical Chiropractic 13 (3) 201‐209, 2010
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Manual Therapy Principles • How do you determine whether the loss of motion is capsular?
• Combined Movements
• Manual Therapy Techniques
– Close Axis
– Traction
– Concave – Convex rule
• How do you select which method to use?
• Where is your motion loss?
• Check Reins to Motion‐
Cross Linking‐Akeson et al
Definition of a “stiff Knee” AAOS
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Time Frame to manipulate a knee
Time frame to debride scar
Rehab
• MWM’s
• Weight Bearing Mob’s
• Stretches and Releases
• Graston or IASTM
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SEQUENCING OF THER EX
• What do you do first?
• Mob?
• Stretch?
Soft tissue releases
FUNCTIONAL STRETCHING
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ROM with Bicycle
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Concave vs. Convex Rules
MULTI PLANE MOBLIZATION
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Joint Mobilization‐Ventral Glide with Tibial
External Rotation
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Combined Motion Mobilization For Flexion‐traction, tibial IR and flex
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Traction with Tibial IR and then flex the Knee
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Summary
• Studies show no one single intervention is more superior
• Combination is effective
• We are all looking for the specific “recipe” of what works for subgroups of patients‐STAY TUNED!!
• References at Johnoseminars.com under manual therapy of the knee section
• Questions or Comments:
• Johnoseminars.com
Thank You!!!