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Purpose To consolidate and expand your knowledge and skills of Manual Therapy.

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Presentation on theme: "Purpose To consolidate and expand your knowledge and skills of Manual Therapy."— Presentation transcript:

1 Purpose To consolidate and expand your knowledge and skills of Manual Therapy

2 Objectives Canadian Manual Therapy history Subjective examination Objective examination –lumbar, pelvis, hip,cervical, TMJ, Treatment approaches including mobilizations, exercise, education and manipulation

3 Definition of Manual Therapy A comprehensive system of diagnosing and treating neuromusculoskeletal disorders involving specific skills, including assessment, mobilization, manipulation and education, in conjunction with exercise, to restore optimal motion, function and/or reduce pain. MTSC Vision 2001

4 Clinical Reasoning Hear See Feel Biomedical Knowledge Clinical Knowledge – knowledge, skill experience

5 Clinical Reasoning The process of drawing conclusions based upon known or presumed facts Development of an accurate diagnosis and prognosis

6 Hypothesis Generation Data collection Interpretation of information Cross-examination Contributing factors Hypothesis modification Treatment Reassessment Prognosis

7 Beginner Systematic approach Gather as much information until diagnosis emerges Check list may be helpful Takes longer to recognize clinical patterns Level 1 pg 4

8 Novice Repertoire of clinical patterns Abandon checklist Lack experience to identify all clinical patterns Often tempted to make assumption

9 Expert Need a superior knowledge base from which to generate a high quality hypothesis Clinical patterns

10 What qualities define a clinical specialist? content knowledge practical knowledge technical skill application of general principles or theory critical analysis Mildonis et al, JOSPT, 1999

11 Expert Intense focused connection with patient, verbal and non Use clinical patterns and inductive reasoning to develop a diagnosis Comfortable with the uncertainty of not knowing the immediate diagnosis

12 Expert Management becomes more efficient and effective “ seeing” the clinical pattern Allows PT to focus on 1 or 2 primary issues Recognize what features are most significant and in need of attention

13 Former Paradigm Unsystematic observations OK Knowing basics OK Common sense enough Clinical experience enough

14 The Danger of Relying on Experience Alone “making the same mistakes with increasing confidence over an impressive number of years.” M. O’Donnell. A Skeptic's Medical Dictionary Is that 25-years of experience or 1-year of experience repeated 25-times?

15 New Paradigm Intuition- misleading Rationale for treatment and discharge may be incorrect Understanding rules to interpret the literature is necessary

16 Why Evidence- based Practice 30,000 biomedical journal articles per year with a 7% increase each year There are over 3,200 physiotherapy articles published per year To keep up to date, a clinician would need to read approximately 10 articles per day If 2 articles are read per day, after 1 year a clinician would be approximately 4 years behind

17 Consequences of Not Keeping Up-To-Date Lag in optimal practice behaviors Clinical practice is opinion driven Patients may be denied best care Patients may selectively know more than clinicians

18 Evidence-based Practice “the integration of best research evidence with clinical expertise and patient values” D.L. Sackett et al, 2000

19 Definition of Manual Therapy A comprehensive system of diagnosing and treating neuromusculoskeletal disorders involving specific skills, including assessment, mobilization, manipulation and education, in conjunction with exercise, to restore optimal motion, function and/or reduce pain. MTSC Vision 2001

20 Aim of Manual Therapy Pain relief Restoration or improvement of function Restoration of an acceptable predetermined level of physical lifestyle Prevention of further episodes Education, communication, documentation

21 Homeostasis Restoration of normal repair processes facilitated and pain is alleviated

22 Diagnosis Is physical treatment a treatment of choice? If so, what type of physical treatment should be used? Manual Therapy must be based upon diagnostics rather than signs and symptoms

23 Scope of Manual Therapy Mobilization, Traction, Manipulation Muscle Energy, PNF Dynamic soft tissue release Muscles rebalancing, muscles co- contraction Stabilization, Exercise Therapy Functional Rehabilitation

24 Cyriax Principle – “ search for physical signs, positive and negative and their interpretation” Selective tissue tension testing Contractile Inert

25 Subjective Assessment Why is it SO Important?

26 List the negatives of a history from the patient’s point of view List the positives from a patient’s point of view What are your goals when starting a subjective assessment?

27 The Art of Listening “ We are in danger of overlooking the simple psychological potency of giving patients a good hearing, listening attentively, giving them the benefit of the doubt, handling them with confidence and skill and simply striving to do our shop floor clinical work with effectiveness. Failure to properly examine the patient may lead to unnecessary mischief.” ……..Grieve 1991

28 Listening is an ART: That is where it differs from hearing Hearing is passive Listening is active Hearing is involuntary Listening demands attention Hearing is natural Listening is an acquired discipline ( the Age ’82)

29 Use our communication skill to help patient understand…… What manual therapy is all about What it can do for them What the treatment will entail What are their options What part they play in recovery and treatment What part they play to maintain their acquired healthy state A Moore + G Jull Manual Therapy 2001

30 Assessment Subjective History Objective - observation - active – passive- resisted Interpretation of Evaluation –Capsular pattern –Resisted findings

31 Treatment Transverse frictions Stretch Manipulation Injections

32 Lower Quadrant Scan Rule out serious pathology Isolate area of dysfunction Identify others areas in the body that may need attention

33 Observation Postural type Gross deformities Gait

34 Clearing Tests Squat Twist Walk (on heels and toes)

35 Active movements – OP if not painful Lumbar Spine flexion, extension, side flexion and rotation Hip flexion, extension, rotation, abduction Knee flexion, extension Ankle dorsi, plantar, inversion, eversion

36 Myotomes L1-2 hip flexion L3 Knee extension L4 Ankle dorsiflexion L5 Gt toe extension, hip abduction S1 PF ankle, eversion, knee flexion S2 Hip extension

37 Dermatomes Light touch – cotton ball, kleenex Sharp- dull – acupuncture needle, paper clip

38 L5 L4 S2 Sensory Testing Lower Quadrant Hoppenfeld’76

39 Reflexes Quad - L3 Hamstrings - L5 Achilles - S1

40 Pathological Reflexes Clonus Babinski Neg Pos

41 Dural SLR Slump Prone knee bend

42 Articular SI stress test – anterior, posterior PA’s lumbar spine – spring tests

43 Perform a lower quadrant scan

44 Kaltenborn Subjective Objective –Cyriax –Plus accessory movements

45

46 Treatment Hyper Hypo Restore normal glide Arthrokinematics – decrease capsular tightness

47 Maitland Concept Open mind Mental agility Mental discipline Logical Methodical process of assessing cause and effect Link with

48 Assessment Subjective Provides guidelines Pain patterns Objective Priorize assessment Active, passive, pain, resistance Accessory movements Salient signs Quadrants Movement diagrams

49 Treatment Interpretation of evaluation Grading Techniques Reassess

50 Maitland “ When trying to improve the quality of the sick joint’s movement by a passive movement technique it is necessary to put your mind inside the joint area and involve yourself emotionally with what the joint is trying to tell you”

51 Grades of Movement

52 Demonstrate + explain use Grade 2 physiological flexion of the knee jt Flexion/adduction/MR grade 3 + hip joint Grade 4 + Plantar flexion MT /IP jt great toe Traction manipulation talocrural joint

53 Evidence-based Practice “the integration of best research evidence with clinical expertise and patient values” D.L. Sackett et al, 2000

54 Evidence-based Practice Admit - do not know it all Need to identify knowledge gaps Process is systematic and critical Prevents belief in evidence that supports preconceived ideas of therapies that are effective

55 Systematic Reviews Meta-analyses Randomized Control Trials Case Control Studies Cohort Studies Ideas, Editorials, Opinions Animal research “Best” Evidence

56 Clinical Expertise The ability to use our clinical skills to rapidly identify each patient’s unique health state.

57 Patient Values This includes a patient’s unique preferences, concerns, and expectations as part of the clinical decision-making and management processes.

58 Treatment Today Outcome measure Improve diagnosis Measure ROM More education – ergonomics Patient more involved

59 Canadian Approach Recognized worldwide Eclectic approach Lamb, Morgan, Fowler, McGregor, Oldham, Lee and many others

60 What must improve Better classification of syndromes Cluster of tests and treatment approaches Improve reporting results of Systematic Reviews

61 What will change Gold standards improve- MRI’s FCAMT’s increase in publishing More recognition for MT research Evaluate mechanisms – apply to techniques

62 “A new orthopaedic stream within the M.Sc. program began in September This program provides training in advanced manual therapy and research methods concurrently” MSc – Orthopaedic Stream

63 Evidence – based Practice Imperfect but necessary

64 Two LBP Cases Discuss the 2 cases Use these headings Contributing Factors Clinical Hypothesis Treatment Approach Prognosis


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