How to Make Manual Therapy -...

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1 How to Make Manual Therapy Functional Title :Manual Therapy of Adult Knee Conditions John O’Halloran PT,DPT,OCS,Cert MDT, ATC,CSCS O’Halloran Rehabilitation and O’Halloran Consulting LLC Cross Country Education Leading the Way in Continuing Education and Professional Development. www.CrossCountryEducation.com To comply with professional boards/associations standards: • I declare that I or my family (do, do not) have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. •Requirements for successful completion are attendance for the full session along with a completed session evaluation form. •Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. HIPPA All persons pertaining to this presentation have verbally given permission and waived their confidential medical information with the understanding this is to enhance the presentation for your higher level of understanding and learning.

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

To comply with professional boards/associations standards:• I declare that I or my family (do, do not) have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship.•Requirements for successful completion are attendance for the full session along with a completed session evaluation form.•Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.

HIPPA

All persons pertaining to this presentationhave verbally given permission and waivedtheir confidential medical information withthe understanding this is to enhance thepresentation for your higher level ofunderstanding and learning.

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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

_

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:

[email protected]

• Johnoseminars.com

Thank You!!!