OMT Lecture 2.pptx Physiotherapy students

Ortho

1. Orthopaedic Manual Therapy (OMT) S. Himalowa LAMU

2. What is a joint?? An articulation btn 2 or more bone ends which may be held together by cartilage reinforced by capsule which is lined by synovial membrane which secretes synovial fluid. Its congruency and strength is enforced by intra & extra capsular cartilage & ligaments such as the semi-lunar cartilages/disc, cruciate & collateral ligaments .

3. Function of a Joint To allow movement of the bone levers of the body: Adequate movement Pain free movement Functional movement To give input to the brain with regard to position/movement in space

4. Pain Sensitive Structures in Joints The capsules of joints, The outer part of the intervertebral discs, The ligaments, The vertebral bodies, bone-ends The dura mater, nerve root sleeve, connective tissue of nerves, Blood vessels Local muscles NOT CARTILAGE

5. Pain from Joint structures Nociceptors activated by : Thermal mechanisms Mechanical mechanisms More commonly intermittent. May be constant, but change with movement Movements in one direction may worsen symptoms, whereas movements in the other direction will improve them The mechanical presentation will improve along with the symptoms

6. Cont.. Chemical mechanism Inflammatory process following trauma or with inflammatory or infective diseases Constant pain; Lasting aggravation of pain by all movements; No movement found to abolish pain Recent onset (traumatic or possibly insidious/gradual) Cardinal signs may be present –swelling, redness, heat, tenderness Yields within 6 months and can be timed Pain lasts longer than mechanical

7. Effect of ageing and disease on joints OA vs RA Ageing = ‟wear & tear ‟ = OA In OA: Weight-bearing may worsen condition; injury-prone joints [knees, hips, cervical, lumbar, CMC1, IPJs] Symptoms increases with age Degenerative cartilage disease; X-rays only show end product = narrowing of joint cartilage and bone thickening

8. No role for strong NSAIDS –only if evidence of inflammatory reaction; only pain management is vital Maintain movement and [initially] normal loading; if cartilage is lost, unload joint & mobilise resultant stiffness of capsule In RA : Most common form of inflammatory arthritis resulting from chronic immune dysregulation Affects capsule & synovial lining, weakens CT Careful application of forces; Mobilise in Gr II & III range

9. How do I assess the functions of a joint? Observation: Swelling, deformity, asymmetry, rhythm of movt ; Movement tests: ROM –P2 or R2? Active Physiological Movt Passive Physiological Movt + Overpressure = Gr III to IV Kinaesthesia/Proprioception Palpation : Swelling, soft tissue changes, joint glide movement etc

10. How do I assess the functions of a joint? Palpation of joint movement: In LPP & CPP In treatment plane or body plane What stops the movement? Pain 2 , Resistance 2 , MS Spasm. Through ROM vs. End of ROM symptoms Passive glide with painful movement (Mulligan)

11. Manual examination of the spinal articular system Passive Accessory Intervertebral Movements , instability tests What do I perceive? = load displacement characteristics Need to know NORMAL feel Passive Access Intervert Movts (PAIVMs) in body plane [Maitland] vs. treatment plane [Kaltenborn/Mulligan] Palpation THROUGH soft tissues

12. How do I restore the functions of a joint? Allow inflammation to subside and injury to heal –create favourable conditions Restore normal gliding movement between joint surfaces Oscillatory of sustained PAM/PPM Grade III, IV Passive glide with active movement Treat joint pain by stimulating the pain-inhibiting pathways (Grade II , III) Change the disc [?protrusion] McKenzie exercises Intermittent sustained traction

13. How do I restore the functions of a joint? Retrain joint sense and deep stabilising muscles to protect Strap/brace/support to: immobilise ?, re- ‟track‟?, support/unload ? Electro-physical modalities for pain: Ice? Heat? Ultrasound?

14. Effect of joint damage on muscle function and proprioception[ Hurley 1997 ] Series of studies demonstrated effect of “arthrogenic reduction” = inability to maximally activate muscles acting across damaged joints leads to muscle weakness and atrophy Joint damage leads abnormal articular afferent information which may decrease alpha-motor neurone excitability and reduce voluntary muscle activation May also decrease gamma-motor neurone excitability and proprioceptive deficits [Rehabilitation increasing alpha- motor neurone excitability which may increase gamma- motor neurone excitability ]

15. Precautions in Manual Therapy & Exercise Osteoporosis, Long-term cortico -steroids, Recent fracture, Cancer, prolonged post-immobilisation , Diseases [e.g. RA] Inflammatory and early Fibroblastic phases of healing SIN patients Severity Irritability Nature

16. Rationale behind different approaches Maitland [ Vertebral & Peripheral joints ] Evaluation and treatment by passive accessory movement -based on clinical reasoning Relating treatment to interpretation of signs & symptoms and to biomedical sciences “Brick wall” theory Approach the treatment of joint pain by observing the outputs [S&S] on this side of the brick wall Then we apply our skills [inputs], to bring about favourable outcomes of the S&S

17. Maitland Thorough and encompassing assessment approach, based on assessment and re-assessment. Relate techniques to 4 categories of joint dysfunction: Pain ; Pain/Stiffness ; Stiffness ; Momentary pain [Find THE pain] Passive accessory movement in LPP Passive physiological movement after 50% AROM (in some cases)

18. Maitland Body plane direction of vertebral pressure/movement [though movt may be caudad /cephalad or med/ lat inclined] Graded : Grade I: beginning of ROM; small amplitude ROM; NOT into resistance Grade II: Beginning of ROM; big amplitude ROM; Not into resistance Grade III: Middle to end ROM ; big amplitude ROM; into resistance Grade IV: EROM ; small amplitude movt , into resistance Rhythm of movement: Passive oscillatory movement at a pace of 2/sec [2Hz]; “Legato”

19. Rationale behind different approaches McKenzie Centralisation of pain Process whereby radiating pain from the spine is sequentially abolished, distally to proximally, in response to therapeutic positions or movements, and includes reduction and abolition of spinal pain

20. McK Extension and List shift

21. The McKenzie Approach Focus on S ymptomatic and mechanical responses Centralisation ; progression of forces Self-treatment ; patient education Contrast with other approaches Repeated movts for assessment Emphasis on patient independence; minimal intervention Exercises used for pain relief

22. McKenzie Syndromes Derangement = disturbance of the normal resting position of the joint surfaces. Centralisation used Dysfunction = mechanical deformation of structurally impaired soft tissues. EROM painful movt used ( supine, knees flexed, stretch annulus fibrosus ) Postural = mechanical deformation of soft tissues & vascular insufficiency arising from prolonged positional/postural stresses Sagittal Ext > Flex

23. Treatment after Injury of CT in Joints After injury the ability of soft tissue to tolerate the demands of functional loading is decreased [tensile/compressive strength less] In the early stages of the healing process techniques should promote collagen synthesis, orientation and bonding In the later stages of healing techniques should promote changes in the visco -elastic responses of the tissue Matching the stage of the condition to management NB [Hunter 1994; 1998]

24. QUESTIONS