Four Cardinal Principles of Joint Mobilization and Joint Play Assessment

Abstract

The teaching and learning of fundamental principles that guide valid and effective assessment and intervention techniques in joint mobilization is a basic foundation to those health professions that make use of manual therapy. Such principles help establish the specificity of manual therapy techniques, the foremost quality of 'best practice.' However, authors of few textbooks or reference books devote space to establishing such fundamental principles for learners and practitioners of manual therapy techniques. The purpose of this paper is to present four cardinal principles that have impressed us, over our years as educators and clinicians, as the foundation for the teaching and practice of sound manual therapy techniques for either joint play assessment or joint mobilization. These principles are utilized in practice from entry-level to master clinicians, they can guide educators as to how to introduce and monitor effective manual therapy skills among students and colleagues, and they can also serve as a source of refreshment for experienced clinicians who desire continuing education for maintenance of their hands-on skills in manual therapy interventions and assessment.     

Diagnosis and Management of Cervicogenic Headache and Local Cervical Syndrome with Multiple Pain Generators

Abstract

Numerous pain generators can be responsible for cervicogenic headache and pain in both the cervical and thoracic regions. A 45-year-old female presented in the clinic with a 20-year history of cervicogenic and migraine headaches, accompanied by a prolonged history of local cervical and interscapular pain. The cervicogenic symptoms were attributed to secondary discrelated changes in the cervical spine, as evidenced by specific provocation behaviors and segmental limitation patterns. The patient was educated regarding the presenting problems, and ergonomic changes were initiated. The limitations were addressed with joint-specific mobilization techniques, accompanied by specific home exercises. The patient demonstrated initial rapid improvements that were characterized by reduced symptoms and increased motion, followed by gradual full motion recovery and resolution of cervicogenic symptoms. This recovery pattern suggests the efficacy of manual techniques in the management of cervicogenic headaches and local cervical syndrome, even in the context of rather prolonged symptoms.     

A Multi-Structural Approach to Treatment of a Patient With Sub-Acromial Impingement: A Case Report

Abstract

Sub-acromial impingement is a condition commonly seen by physical therapists, however little evidence is available regarding the efficacy of this treatment. This case report describes the use of manual therapy and exercise, using a multi-structural approach to manage this condition. The subject was a 48-year-old retired physiotherapist complaining of recurrent shoulder pain during daily activities, although her daily function was not limited. Passive joint mobilization techniques of the cervical spine, costovertebral joints, and the glenohumeral joint as well as soft tissue mobilization techniques of the rotator cuff muscles were used. Exercises were prescribed to “set” the scapula in an optimal position and to facilitate and strengthen the rotator cuff muscles. After two treatments, the patient consulted an orthopaedic surgeon due to imminent decrease in funding for her treatment and a cortisone injection was administered. This decreased her pain immediately by 90%. However, two months later she attended three further physical therapy treatments because of recurrence of the pain. Six months after these treatments she was still pain-free. This case illustrates that physical therapy can be effective in the treatment of sub-acromial impingement, using a multi-structural approach to treatment.     

2003 Manual Therapy Awards and Abstracts

Abstract

Lateral epicondylalgia or tennis elbow is a prevalent musculoskeletal disorder that is characterized by lateral elbow pain often associated with gripping tasks. The underlying pathology remains to be fully elucidated; however, evidence indicates that the disorder does not involve an inflammatory process but rather impairments of the pain and motor systems as well as morphological changes in the structure of both the extensor carpi radialis brevis muscle and tendon. Although the most efficient management approach remains controversial, there is a growing body of literature reporting the effects and underlying mechanisms of joint manipulation in the management of lateral epicondylalgia. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. In addition to presenting this evidence, this paper describes proposed underlying physiological mechanisms of joint manipulation associated with the observed clinical effects. We propose that this information will be useful for the physical therapist in making clinical decisions regarding the selection of treatment technique for the management of patients with lateral epicondylalgia.     

Abstracts: AAOMPT Conference, 2002

Abstract

Background/Purpose: The purpose of this case report is to describe the clinical management of a patient with sacroiliac joint dysfunction (SIJD) and a concomitant asymmetrical hip-joint rotation range of motion. The patient was a 53-year-old male whose chief complaint was right low back pain (LBP) that interfered with work and leisure activities. Physical therapy consisted of manual therapy, stretching, and postural education to address SIJ and hip motion abnormalities. At the conclusion of 6 visits, the hip-joint rotation range of motion was more symmetrical. The patient reported self-correction of unilateral standing and sitting postures. He returned to full-time work and to playing golf, and he rated pain at 0-1/10. This patient's asymmetrical hip-joint rotation range of motion may have been associated with SIJD, either as a result of trauma or subsequent habitual postural adjustments. Clinician awareness of the possible relationship between SIJD and asymmetrical hip joint rotation range of motion is recommended.     

Novel use of a manual therapy technique and management of a patient with peroneal tendinopathy: a case report

Peroneal tendinopathy is an uncommon but underappreciated source of lateral hindfoot pain and dysfunction. There is a paucity of literature describing optimal intervention for those suffering with pain secondary to peroneal tendinopathy. The purpose of this case report is to describe the evaluation and treatment incorporating manual therapy and therapeutic exercise for a patient diagnosed with peroneal tendinopathy. The patient was a 50 year-old female with a history of chronic lateral ankle pain and whose presentation was consistent with peroneal tendinopathy. Despite attempts to improve pain and function with over-the-counter orthotics, manual therapy to a hypomobile talocrural joint, and strengthening of the peroneal tendons, successful response was not reported until a lateral calcaneal glide was added. Improvement in impairments (pain, talocrural dorsiflexion, unilateral heel raises, and Star Excursion Balance Test) and function (Lower Extremity Functional Scale and Global Rating of Change), were observed over a course of eight visits. The patient was able to return to work and her recreational work out routine without limitations. In conclusion a successful physical therapy intervention for a patient with peroneal tendinopathy included a unique manual therapy technique, the lateral calcaneal glide, in conjunction with other manual therapy techniques and a structured home exercise program.     

Use of Mobilization with Movement in the Treatment of a Patient with Subacromial Impingement: A Case Report

Abstract

Mobilization with movement (MWM) is a fairly new therapeutic technique commonly used by physical therapists. The purpose of this case report was to describe the use of MWM in the treatment of a 27-year old left-hand dominant male patient referred to physical therapy with a diagnosis of supraspinatus tendinopathy secondary to impingement. Interventions consisted of MWM and other manual therapy techniques, modalities, and therapeutic exercises. Outcome measures used included goniometric active range of motion (AROM) measurements and manual muscle tests of the shoulder, impingement tests, and the Shoulder Pain and Disability Index (SPADI) and Short Form-36 (SF-36) questionnaires. Specific outcome measures used to describe the response to MWM of the glenohumeral joint included the Numeric Pain Rating Scale (NPRS) and goniometric measurement of abduction AROM. After the first MWM treatment (session 2/12), the 6/10 pre-application NPRS score during shoulder abduction was reduced to 3/10 post-application; however, abduction AROM did not improve (95°). At the final MWM treatment (session 6/12), the pre-application NPRS score during abduction was reduced from 3/10 to 0/10 post-application; abduction AROM increased from 130° to 175°. After 12 sessions, there was a decrease from moderate pain (7/10) to little or no pain (0-1/10) during active shoulder abduction; restricted (95°) to full shoulder abduction active range of motion (180°); and an improvement in the SPADI score from 45% to 8% with no pain or ADL activity difficulty scores >2. This case report indicates that MWM may be an effective treatment intervention for patients with subacromial impingement. Future research is needed to study the efficacy and mechanisms of this treatment technique.     

Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor

Abstract

Use of manual therapy in the form of manipulation and massage is evident in the earliest recordings of history. Today, manual therapy is an evidence-based practice that can be used with predictable results in the treatment of a variety of neuromusculoskeletal problems. However, for some manual therapists, treatment is still based on a belief system that incorporates vitalism, energy healing, and other metaphysical concepts. Cooperation of practitioners in researching the effects of manual therapy would require uniformity based upon the guidelines of science, following rules for selection of an evidence-based therapy that produces predictable and replicable results. Such an approach would not allow contamination by dogma or by an agenda that is designed more to support a belief system than to find the truth. The chiropractic profession, which began with a founding father in 1895, is identified primarily by its use of manipulation. But chiropractic is based upon a vertebral subluxation theory that is generally categorized as supporting a belief system. The words "manipulation" and "subluxation" in a chiropractic context have meanings that are different from the meanings in evidence-based literature. An orthopedic subluxation, a partial dislocation or displacement of a joint, can sometimes benefit from manipulation or mobilization when there are joint-related symptoms. A chiropractic subluxation, however, is often an undetectable or asymptomatic "spinal lesion" that is alleged to be a cause of disease. Such a subluxation, which has never been proven to exist, is "adjusted" by chiropractors, who manipulate the spine to restore and maintain health. The reasons for use of manipulation/ mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by most chiropractors. Only evidence-based chiropractors, who have renounced subluxation dogma, can be part of a team that would research the effects of manipulation without bias.     

Influential Variables Associated with Outcomes in Patients with Cervicogenic Headache

Abstract

Cervicogenic headache (CGH) is a common sequela of upper cervical dysfunction with a significant impact on patients. Diagnosis and treatment have been well validated; however, few studies have described characteristics of patients that are associated with outcomes of physical therapy treatment of this disorder. A retrospective chart review of patient data was performed on a cohort of 44 patients with CGH. Patients had undergone a standardized physical therapy treatment approach that included spinal mobilization/manipulation and therapeutic exercise, and outcomes of treatment were determined by quantification of changes in headache pain intensity, headache frequency, and self-reported function. Multiple regression analysis was utilized to determine the relationship between a variety of patient-specific variables and these outcome measures. Increased patient age, provocation or relief of headache with movement, and being gainfully employed were all patient factors that were found to be significantly (P<0.05) related to improved outcomes.     

Cervicogenic Dizziness: A Case Report Illustrating Orthopaedic Manual and Vestibular Physical Therapy Comanagement

Abstract

The diagnosis and treatment of patients with dizziness of a cervical origin may pose a challenge for orthopaedic and vestibular physical therapy specialists. A thorough examination, which consists of a screening examination to rule out pathologies not amenable to sole physical therapy management and, if indicated, a physical therapy differential diagnostic process incorporating both cervical spine and vestibular tests and measures, may indicate an appropriate course of management. The treatment progression is then based on patient signs, symptoms, and response to physical therapy interventions. This case study describes the diagnosis, treatment, and outcomes of a patient with cervicogenic dizziness co-managed by a vestibular and an orthopaedic manual physical therapist.     

Interaction between Trigger Points and Joint Hypomobility: A Clinical Perspective

Abstract

The relationship between muscle trigger points (TrPs) and joint hypomobility is frequently recognized by clinicians. Among different manual therapies aimed at inactivating muscle TrPs, ischemic compression and spinal manipulation have shown moderately strong evidence for immediate pain relief. Reduction of joint mobility appears related to local muscles innervated from the segment, which suggests that muscle and joint impairments may be indivisible and related disorders in pain patients. Two clinical studies have investigated the relationship between the presence of muscle TrPs and joint hypomobility in patients with neck pain. Both studies reported that all patients exhibited segmental hypomobility at C3-C4 zygapophyseal joint and TrPs in the upper trapezius, sternocleidomastoid, or levator scapulae muscles. There are several theories that have discussed the relationship between TrP and joint hypomobility. First, increased tension of the taut muscular bands associated with a TrP and facilitation of motor activity can maintain displacement stress on the joint. Alternatively, it may be that the abnormal sensory input from the joint hypomobility may reflexively activate TrPs. It is also conceivable that TrPs provide a nociceptive barrage to the dorsal horn neurons and facilitate joint hypomobility. There is scientific evidence showing change in muscle sensitivity in muscle TrP after spinal manipulation, which suggests that clinicians should include treatment of joint hypomobility in the management of TrPs. Nevertheless, the order in which these muscle and joint impairments should be treated is not known and requires further investigation.     

Possible manifestation of temporomandibular joint dysfunction on chiropractic cervical X-ray studies

OBJECTIVE: Our purpose was to show that biomechanical alterations toward and away from normal on x-ray studies may be the result of changes in temporomandibular joint dysfunction and to discuss possible neurologic explanations for this phenomenon. CLINICAL FEATURES: Two patients are discussed; the first had migraine headache symptoms, and the second had chronic hypomobility of mandibular opening, dizziness, headache, and neck pain and stiffness. In both patients mensuration changes in different types of cervical x-ray studies were noted in conjunction with exacerbation of, and elimination of, temporomandibular joint dysfunction. INTERVENTION: Comanagement of these cases was done with dental professionals. Chiropractic treatment included vectored/linear, upper cervical, high-velocity, low-amplitude chiropractic manipulation of the atlas vertebra, diversified manipulation, myofascial therapy, stretch and spray procedures, and soft tissue manual techniques. CONCLUSION: Temporomandibular joint dysfunction may cause cervical muscular and spinal biomechanical changes that may become visible and change on x-ray examination. Further investigation into this phenomenon is recommended.     

Letters to the Editor

Abstract

The purpose of this case series was to explore the effects of tibio-femoral (TF) manual traction on pain and passive range of motion (PROM) in individuals with unilateral motion impairment and pain in knee flexion. Thirteen participants volunteered for the study. All participants received 6 minutes of TF traction mobilization applied at end-range passive knee flexion. PROM measurements were taken before the intervention and after 2, 4, and 6 minutes of TF joint traction. Pain was measured using a visual analog scale with the TF joint at rest, at end-range passive knee flexion, during the application of joint traction, and immediately post-treatment. There were significant differences in PROM after 2 and 4 minutes of traction, with no significance noted after 4 minutes. A significant change in knee flexion of 25.9°, which exceeded the MDC₉₅, was found when comparing PROM measurements pre- to final intervention. While pain did not change significantly over time, pain levels did change significantly during each treatment session. Pain significantly increased when the participant's knee was passively flexed to end range; it was reduced, although not significantly, during traction mobilization; and it significantly decreased following traction. This case series supports TF joint traction as a means of stretching shortened articular and periarticular tissues without increasing reported levels of pain during or after treatment. In addition, this is the first study documenting the temporal aspects of treatment effectiveness in motion restoration.     

High-Velocity Thrust Technique for Traumatic Onset Lateral Elbow Pain

Abstract

A 35 year-old male presented to physical therapy following a fall onto his outstretched right hand. He developed pain and dysfunction in the right lateral epicondyle region. The patient was assessed and received a physical therapy diagnosis of abducted ulna syndrome. The patient was treated with a high-velocity, low-amplitude manipulation technique to the humeroulnar joint. This technique coincided with a restoration in the patient's normal function, along with an elimination of painful symptoms. This case study suggests that a high-velocity, low-amplitude manipulation technique performed by a physical therapist may play an important role in the successful treatment of traumatically induced lateral epicondyle pain.     

Subject Index

Abstract

Shoulder pain is a common orthopedic condition seen by physical therapists, with many potential contributing factors and proposed treatments. Although manual physical therapy interventions for the cervicothoracic spine and ribs have been investigated for this patient population, the specific effects of these treatments have not been reported. The purpose of this investigational study is to report the immediate effects of thoracic spine and rib manipulation in patients with primary complaints of shoulder pain. Using a test-retest design, 21 subjects with shoulder pain were treated during a single treatment session with high-velocity thrust manipulation to the thoracic spine or upper ribs. Post-treatment effects demonstrated a 51% (32mm) reduction in shoulder pain, a corresponding increase in shoulder range of motion (30°-38°), and a mean patient-perceived global rating of change of 4.2 (median 5). These immediate post-treatment results suggest that thoracic and rib manipulative therapy is associated with improved shoulder pain and motion in patients with shoulder pain, and further these interventions support the concept of a regional interdependence between the thoracic spine, upper ribs, and shoulder.     

A randomized clinical trial of manual therapy for cervico-brachial pain syndrome -- a pilot study

Cervico-brachial pain syndrome is an upper quarter pain condition in which mechanosensitive neural tissue is considered a primary feature. A single-blind randomized controlled trial was conducted to determine the clinical effect of two manual therapy interventions. Thirty subjects (20 females and 10 males) were randomly allocated to one of three groups - one of two manual therapy intervention groups or a control group. One manual therapy intervention group consisted of passive techniques aimed at mobilizing neural tissue structures and the cervical spine. The other involved indirect manual therapy techniques with a focus on articular components of the gleno-humeral joint and thoracic spine. The treatment period lasted 8 weeks in total and was combined with a home exercise programme. Following the 8-week baseline period the control group were crossed over into the specific neural tissue manual therapy group. Pain visual analogue scale (VAS), the short-form McGill pain and Northwick Park neck pain questionnaires were completed before, midway and after the treatment period. The findings suggest that both manual physiotherapy interventions combined with home exercises are effective in improving pain intensity, pain quality scores and functional disability levels. A group difference was observed for the VAS scores at 8 weeks with the neural manual therapy technique having a significantly lower score.     

Effect of Mobilization of the Anterior Hip Capsule on Gluteus Maximus Strength

Abstract

Loss of hip extension is often compensated for by extension of the lumbar spine. This compensation can result in hypermobility and ultimately be a source of low back dysfunction and pain. Joint mobilizations have been known to return physiologic and accessory motion to hypomobile structures. Mobilization has also been demonstrated to improve muscular strength when secondary to joint hypomobility. The purpose of this study was to determine the usefulness of posteroanterior (P-A) hip-joint mobilization in improving strength of the gluteus maximus muscle. Forty subjects were randomly assigned to a control group (Grade I P-A mobilization) and an experimental group (Grade IV P-A mobilization). The subjects performed a pretest/posttest set of five isometric repetitions on the Cybex Norm? isokinetic machine. The peak torque was determined for both pretest and posttest measurements. The data collected were analyzed using an independent t-test with a significance level of p < .05. The results demonstrated a statistically significant difference between the experimental and control groups (t=1.68, p=0.002). This study demonstrated a significant increase in gluteus maximus strength in response to Grade IV P-A mobilizations performed on the anterior hip capsule. Clinicians can utilize these findings in everyday practice to improve muscle strength by integrating manual therapy with therapeutic exercise.