Maitland’s Concepts Selected Pages from Yearlong Course Theory Manual · PDF fileAMSPT Yearlong Course Theory Manual Australian Musculoskeletal Physical Therapy 2011 T 1

AMSPT Yearlong Course Theory Manual

Australian Musculoskeletal Physical Therapy 2011 T 1

Theory Manual Contents (add a T in front of page number)

Abbreviations and Symbols ................................................................................................................2

Maitland’s Concepts ..........................................................................................................................4

Standards for Intermediate level Manual Physical Therapy Practice ....................................................7

Components of the Subjective Evaluation ......................................................................................... 10

Subjective Exam Form ...................................................................................................................... 13

SINSS ............................................................................................................................................... 15

SINSS Worksheet ............................................................................................................................. 22

Contraindications and Precautions ................................................................................................... 24

Components of the Objective Examination ....................................................................................... 27

Comparable Sign .............................................................................................................................. 29

Movement Diagrams ........................................................................................................................ 30

Grades of Movement ....................................................................................................................... 32

Clearing ........................................................................................................................................... 34

Planning the Objective Examination ................................................................................................. 40

Manual Therapy Treatment Selection Part 1 ..................................................................................... 45

Re-assessment ................................................................................................................................. 56

Clinical Reasoning ............................................................................................................................ 61

Neurodynamics ................................................................................................................................ 68

Manual Therapy Treatment Selection Part 2 ..................................................................................... 78

Mechanisms of Pain ......................................................................................................................... 83

Progression of Treatment ................................................................................................................. 98

Errors in Clinical Reasoning ............................................................................................................ 100

Screening for Non-Neuromusculoskeletal Disease ........................................................................... 102

Clinical Patterns: The Characteristics of Common Presentations ..................................................... 107

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Abbreviation Meaning

Rot Rotation

RTS Return to sleep

SG Side glide (AKA shift correction)

STFJ Superior tibiofibular joint

SRUJ Superior radioulnar joint.

Tx Thoracic

TFJ Tibiofemoral joint

ULNT Upper limb neurodynamic test

2/12 2 months

2/52 2 weeks

√ Full active movement no pain overpressure applied (e.g. F: √ OP PCx)

√√ Full APM no pain OP pain free resistance normal. (also used as all clear

for complete subjective and objective exam sections)

Right Rot. The side the arrow is on is the direction of Rot. Used upside

down by some people

LF

Unilateral posteroanterior (UPA) pressure performed on the right sideT6

Unilateral posteroanterior over TP performed on the right

Unilateral posteroanterior over the right rib angle

Anteroposterior (AP)

Posteroanterior pressure (PA AKA central PA in spine)

Unilateral anteroposterior pressue (UAP)

↕ Combined AP/PA

(med) Medial glide

(lat) Lateral glide

Transverse pressure in the spine

(caud) Longitudinal caudad glide. Manual traction in the lumbar spine

(ceph) Longitudinal cephalad glide. Manual traction in the cervical spine.

Shift/deviation denoted on the body chart.

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Standards for Intermediate level Manual Physical Therapy Practice

Introduction

Physical Therapy School educates PTs in the knowledge and

practical skills required to practice Physical Therapy across a

wide variety of disciplines. The depth of manual physical

therapy training in PT school is highly variable creating the

need for post-graduate manual therapy programs. These post-

graduate programs could be at the intermediate level, such as

this yearlong course, or at the advanced level, like the Kaiser

Permanente Fellowship Program or the Masters in Manipulative

Therapy programs offered in the UK and Australia.

Currently, there is considerable variation in the specifics of

orthopedic practice among physical therapists. In our opinion,

to be successful in Manual Therapy, Orthopedic and Sports

Physical Therapy therapists need to maintain practice standards

that are above those seen in many PT clinics. The following

section is to help yearlong students recognize what it takes to be

successful in Manual Therapy. Hopefully, all of you are

already meeting or exceeding the following standards. Students

are expected to acquire the knowledge and skills necessary to

meet each of the standards prior to the end of the course.

Standards for Intermediate level Manual Physical Therapy Practice:

Therapeutic Philosophy and Beliefs

1) Therapists should accept responsibility for the management of each patient’s problem.

2) Therapists should attempt to exhaust all possible Manual Therapy and Physical Therapy options

prior to concluding one-on-one PT can no longer help.

3) For Physical Therapy to be effective the Physical Therapist needs to spend time directly

evaluating, treating and educating each client.

4) Therapists should believe that every client can benefit from skilled Manual Therapy/Physical

Therapy (except those individuals with non-musculoskeletal disorders).

5) Doing the very best you can possibly do for each client will result in maximum patient

improvement and therapist growth. The quality of how you practice is the primary determinant

of how well you advance clinically.

6) The patient is always given the benefit of the doubt.

7) Failure for a patient to improve should force you to reflect on your knowledge and skill, and the

quality of care you have been providing.

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Components of the Subjective Evaluation

Category/Order Information Gathered Common Questions Information Used For

Main Complaint/Kind of disorder

* Reason for patient seeking help. * Pain, stiffness, giving way, instability, weakness, loss of function, Post-trauma (injury/surgery).

* “As far as you are concerned, what do you feel, is you main problem, (at this stage)?”

* Function limitations. * Management * Nature

Patient Profile/Functional Loss

* Age, marital status, living situation, kids, work, exercise etc. * Normal activity level. * Begin to appreciate emotional demands of the patient. * Current functional limitation (ADL, work, sport, exercise etc)

* “How do you keep your self busy?” * “Do you live alone?” * “Is there anything ‘it’ stops you from doing?”

* Function limitations * Contributing factors * Management * Severity * Prognosis

Body Chart/Area and type of Symptoms

* Map all areas of symptoms. Label by numbers or code, E.g. P1, P2 or P-Lx, P-Leg. * Palpate to confirm exact location of symptoms. * Label the “worst” area according to the patient. * For all areas label I/M vs Const, description, depth and severity. * Clear adjacent areas. * Ask about N/T. * Try to establish relationships between the symptoms.

* “Show me where the worst area is?” * “Do you get anything here?” * “Do you get any numbness or tingling?” * ”Is it there all the time or does it come and go?” * ”Is it deep down or on the surface?” * “How would you describe it?” * “Is it mild, moderate or severe?” * ”On a scale of 0-10. Zero being no pain and 10 being the most pain you can imagine feeling, how much is it when it is at its worst?” * “Are they related?” * “Do they come at the same time?” * “How is it in the ____ when you get it in the _____?” * “Do you ever get it in the ____ when you don’t have it in the _____?”

* Pathobiological mechanisms * Source of the symptoms * Severity * Nature * Management * Irritability * Prognosis * Establish a baseline

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Contraindications and Precautions

Caution with mobilization grade I-IV

1. The presence of segmental neurological signs (loss of

sensation, power and/or reflex).

Extra care should be taken with movements that close

the intervertebral foramina on the painful side (more for

the cervical spine).

2. Inflammatory Arthritis (RA, Ank spond, Gout)

Except in the Acute inflammatory stage

Treatment into resistance should be avoided in the

cervical spine due to painless weakening of its

ligamentous structures.

3. Osteoporsis/Osteopenia. Often only suspected due to

advanced age (especially menopausal women), post

radiotherapy, long-term oral steroid or anticoagulant

therapy.

Avoid higher grades, long lever arm techniques, axial

rotation and localized pressure.

Must be especially careful in the thoracic spine, ribs,

neck of femur or neck of humerus.

4. Structural Instability. Such as that from spondylolisthesis or

recent dislocation.

Mobilization should not be done in a fashion that may

increase instability. Occasionally gentle treatment into

resistance in the direction of the instability can be useful

in restoring pain free range.

5. Hypermobility.

6. Children and those still growing. Forceful mobilization and

long lever techniques may stress the epiphysial plates and

interfere with normal growth.

7. Pregnancy.

8. Signs and symptoms of vertebro-basilar Insufficiency (VBI)

or carotid artery compromise. Careful mobilization (except

rotation) with constant monitoring of VBI symptoms can be

performed.

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Compiling a Movement Diagram

1) Find P1

2) Move to the limit. Where in

range is it? What is it (R, P or

S)? Qualify the limit. Note that

in this example the limit is R2. It

could have easily been P2 or S2.

3) Map the behavior of pain from

P1 to the limit. Qualify its

intensity at the limit.

4) Map behavior of other

qualities.

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Planning the Objective Examination

Introduction

The objective evaluation is a dynamic process. The specific

techniques used in each evaluation are selected based primarily on

the information gathered in the subjective examination. The

subjective presentation of each client will result in an objective

evaluation that is individual to each client.

Therefore, there needs to be a planning process to ensure the

evaluation techniques selected meet the needs determined from the

subjective examination. As your objective examination progresses

the plan will be reviewed and modified based upon previously

gathered info.

Goals of the Objective Evaluation:

1. Ensure that Manual/Physical Therapy treatment is safe and

indicated

2. Ensure that the person’s problem is musculoskeletal in nature

3. Test hypotheses developed in the subjective exam

4. Develop new hypotheses

5. Locate the most comparable signs

6. Discover treatment techniques

7. Establish a baseline for reassessment

Factors to consider when planning the OE:

1. What areas/structures to examine

2. Complete exam or clearing exam of each area

3. What level of symptom reproduction is appropriate

4. Appropriate vigor for the exam

5. How much examination to perform on day 1

6. What follow-up exam is required at future visits

7. Is a neurological exam (or other special tests) indicated

8. Safety

What Structures to Examine:

When deciding what structures to examine there a two general rules

that are useful:

1. Examine all structures under the area of symptoms, as well as

any structure that can refer into the area of symptoms.

2. Examine joints above and below the involved area

For the sake of planning it is a good idea to list the musculoskeletal

structures under the area of symptoms, and the structures (non-

musculoskeletal structures to be discussed later) that might refer

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into the area of symptoms. See example below for a patient

complaining of shoulder pain.

Example for a person presenting with shoulder pain:

Structures under

the area of symptoms

Structures that could refer

into the area of symptoms

Glenohumeral Peri-articular eg:

o Fibrous capsule

o Synovial capsule

Glenohumeral intra-articular eg:

o Articular surfaces

o Glenoid labrum

Subacromial bursa

Rotator cuff tendons

Long head of biceps tendon

AC joint

Deltoid muscle

Nociceptive referred pain from a cervical spine

structure eg:

o Disc wall

o PIV (facet) joint

o Ligament

o Muscle

Neurogenic referred pain from cervical nerve

root

Neurogenic referred pain from brachial plexus or

peripheral nerve eg: suprascapular nerve

Thoracic spine

Scapular muscle Trigger point

Elbow

Technically, all of both lists need to be examined. However, it

would not be possible to examine everything on day 1. It would

not even be possible to completely examine a few structures on day

1.

After looking at your 2 lists, think about the other subjective data

you have and decide which structures are more likely to be

involved (you are ranking the hypotheses). The 1st and maybe 2

nd

ranked hypothesis will need a complete (full) exam. Lesser ranked

structures are appropriate for a clearing exam. Some structures

will have to be evaluated on day 2 or 3.

1. Circle the structures needing a complete exam on day 1.

o The complete exam is everything highlighted in gray on the

objective examination table at the beginning of each body

part in the lab manual.

2. Asterisk the structures needing a clearing exam on day1.

o The components of the clearing exam are listed above in

the clearing lecture notes.

o If the clearing exam finds a notable abnormality then a

complete evaluation is warranted by day 3

3. Ideally the remaining un-circled or un-asterisked structures

should be examined by day 3

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How many areas you evaluate on day 1 depends on how efficient

you are, how much time you have, the strength of the other

subjective data and the patient’s expectations.

Appropriate Symptom Reproduction

In general we are looking to fully reproduce all of the patient’s

symptoms in the objective examination. This is a very important

component of the approach. However, there will be certain

situations where it is inappropriate to fully reproduce symptoms.

The following list is the therapist’s options regarding symptom

reproduction for each area of symptoms:

1. Short of P1

2. Got to P1 but not beyond (first onset or increase of symptoms)

3. Partial reproduction (Past P1 but short of P2)

4. Complete reproduction of symptoms. This would be to P2 or P

“prime” (intensity of pain felt at R2 or S2).

Occasionally, it will be appropriate to fully reproduce one area of

symptoms but not others.

Cases when symptoms should not be fully reproduced:

1. Pain Dominant (more coming about this): Still attempt to

reproduce symptoms but stop at P1. In some very Severe and

Irritable cases the patient is asked to “stop just before your

symptoms would increase”.

2. Severe: If pain dominant, go only to P1. If stiff dominant, go

for partial reproduction (somewhere between P1 and P2)

3. Irritability: In theory, irritability limits the vigor and dosage of

evaluation but it also would be prudent to go for partial

reproduction of symptoms in irritable cases.

4. Patient Preference: Certain patients may give you clues that

they are not going to tolerate full reproduction of symptoms.

5. Ongoing Central Sensitization: Fully reproducing symptoms in

persons with ongoing central sensitization may increase central

sensitization, effectively worsening their condition. Choose P1

or partial reproduction.

Exam Vigor, Duration and Direction of Movement

In most patients it is safe to examine any direction of movement

with forces up to the physiological limit of the joint or tissues (this

is known as R2).

However, there are exceptions:

1. Contraindications/precautions: The known or suspected

presence of contraindications will require that the exam is

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limited (see contraindications and precautions lecture notes).

2. Irritable: Limit the number of test movements. A good rule of

thumb is to limit active physiological movement testing to 1 or

2 movements. How much you limit the quantity of the

remaining examine is variable. Also it is a good idea to limit

the vigor of testing but how much you do is dependant on the

clinical presentation. At least a plus or minus (25%) is a good

rule of thumb.

3. Post-surgical or diagnostic precautions: Communication from

the MD will give you a general idea about restricted

movements, but you may have to determine specifics based

upon their general guidelines.

Excluding the cases described above exam vigor is dependant upon

symptom reproduction. If symptoms are not reproduced with

Active Physiological Movements then Overpressure is used. If

Overpressure fails to reproduce symptoms then use Combined

Movements. If Passive Accessory Movements do not reproduce

symptoms then they can be repeated again with the body part at the

physiological limit or position of emphasis (POE).

Neurological Exam and Special Testing

The Nature, clinical presentation or special question responses may

indicate the need for special testing or a neuro exam.

1. Segmental Neurological Exam: Indicated when there are

radiating symptoms that extend beyond the gluteal fold for

lower quarter patients or the acromion for upper extremity

patients. Also indicated when the patient complains of

paresthesias (N&T).

2. Peripheral Nerve Neurological Exam: Indicated when the

subjective and objective exam suggests the possible

involvement of a peripheral nerve.

3. Central Neurological Exam: Babinski and clonus are indicated

when the patient reports paresthesias in a glove and sock

distribution and/or ataxia. Also consider checking for tone and

coordination.

4. VBI testing: Indicated when the patient complains of the 5Ds

or Nausea or as part of your pre-grade V screening.

5. Stability Testing: Indicated when instability is suspected due

to a history of trauma or repetitive injury or to fully examine an

area.

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What if the features don’t fit?

Sometimes your objective exam does not fit with your subjective

exam. This could result from the following reasons:

You missed subjective info and need to re-rank hypotheses.

Therefore, modifying the plan for your OE.

The person has a dominant component of ongoing central

sensitization.

It is a non-musculoskeletal condition. The first step in

screening for non-musculoskeletal disease is making sure that

the objective examination is consistent the musculoskeletal

dysfunction necessary to produce the subjective complaints.

Summary

1. Consider structures under the area of symptoms and structures

that can refer into the area of symptoms

2. Using other subjective evidence, such as the aggravating

factors, the history, and relationships between symptomatic

areas, rank hypotheses.

3. On day 1 perform a complete evaluation of your top hypothesis

and clear 1 or 2 other highly ranked hypotheses (with a clearing

exam).

4. Perform a neuro exam on day one if indicated.

5. Appropriately limit the vigor, duration and pain reproduction if

the disorder is Severe or Irritable.

6. It is important to have a reason for each step of your

evaluation.

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Clinical Patterns: The Characteristics of Common Presentations

The clinical presentation of a patient presenting to Physical Therapy will be familiar or

unfamiliar to the Physical Therapist. When faced with an unfamiliar disorder clinicians will be

using primarily hypotheticodeductive reasoning. Keep in mind that people with the same

diagnosis will present quite differently, some being familiar to the therapist, and others

unfamiliar.

When treating a familiar presentation clinicians will use a greater component of inductive

reasoning. This type of reasoning is known as clinical pattern recognition. Once a familiar

pattern is recognized, and confirmed, an effective management plan becomes known. The

clinical patterns a therapist knows develop with experience using deductive reasoning and from

the knowledge base of the profession. As a starting point therapists should be familiar with the

following common clinical presentations and the management strategies traditionally used.

Overtime therapists will develop their own list of common characteristics to go with these

patterns, as well as develop additional patterns.

Beware: Pattern recognition is only one component to patient management and it can not be

used in isolation. The hypothesis testing and reassessment process used with deductive

reasoning must always accompany pattern recognition. In addition, little of the pattern

characteristics and management strategies have been validated. It is good to remember that

knowing the location of the source of the symptoms will rarely identify the most effective

management. Predicting which treatment will be most effective comes from empirical research

if available or synthesizing a collection of subjective and objective data.

Lumbosacral Clinical Patterns

Subjective Characteristics Objective Characteristics

Management Strategies

Acu

te D

isco

gen

ic P

ain

(no

ner

ve r

oo

t in

volv

e)

Younger

Central &/or Unilateral LBP

+/- Non-dermatomal but/posterior thigh pain

Aggravated by sust sit, bending and ½ Flex

Onset day of or day post specific movement or sustained Flexion activity

Resting pain

+/- lateral shift

Painful limitation of APM flexion

Extension limited by stiffness or pain

Normal Neurodynamic Tests

Normal LE Neuro Exam

PAIVMs comparable

If contralateral shift present closing Physiological techniques best (SG, Rot, LF)

If no shift determine if closing or opening is more effective

Grades need to be into resistance respecting symptoms even if pain dominant

HEP: EIL and/or SG if closing effective

Postural advice +/- Taping

Long term goal restore extension and improve trunk muscle control

Fac

et A

rth

rop

ath

y Unilateral LBP

Insidious onset or traumatic

Mechanical in Nature

Aggravated by closing or endrange opening

APM: mild loss of motion with pain reproduction

Most comparable with Unilateral PA

Normal Neurodynamics

Grade IV ++ or V opening

Unilateral PA

Self mobilization

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Thoracic Clinical Patterns

Thoracic PIV Joint Arthropathy:

Usually

Present

Often

Present

Occasionally

present

Management

Unilateral posterior pain

Aggravated by twisting

Painful limitation of Rot and LF to

same side

Stiffness and pain reproduction

with UPA (PIV)

Slump: Normal

Agg by deep breath

Painful limitation of Rot

and LF to opposite side

Stiffness and pain

reproduction with CPA

Stiff and pain reproduct

with UPA (PIV)

Unilat ant pain

UPA worst over

TP

Thoracic Disc:

Usually

Present

Often

Present

Occasionally

present

Management

Central Thoracic pain

Aggravated by Flexion of thorax

Stiffness and pain reproduction

with CPA

Tx APM limited and reproductive

of pain

Agg by flex of neck

Pain through

chest to sternum

Stiffness and pain

reproduction with

UPA

Acute Thoracic nerve root:

Usually

Present

Often

Present

Occasionally

present

Management

Constant severe pain, radiating

along line of rib toward anterior

chest.

Worsened by Closing APM

Slump : Clinically relevant

Severe pain with UPA

Worsened by

Opening APM

Slump:

neurogenic

responce

T4 Syndrome:

Usually

Present

Often

Present

Occasionally

present

Management

Bilateral N/T whole hand

Clinically relevant response with

ULNT

Stiff++ CPA T4 (T2-T7)

Bilateral N/T whole

hand & forearm

C/O Mid thoracic pain

UE symptoms

reproduced with CPA

Bilat N/T whole

arm

Unilat N/T whole

arm

UE pain instead

of N/T

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Yearlong Course

Theory Manual

Documents

Maitland’s Concepts Selected Pages from Yearlong Course Theory Manual · PDF fileAMSPT Yearlong Course Theory Manual Australian Musculoskeletal Physical Therapy 2011 T 1