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Reducing derangements Progressing contractile dysfunction Mechanical Diagnosis and Therapy The lower extremity Mark Miller Beata Smela Jerry Pica Richard.

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Presentation on theme: "Reducing derangements Progressing contractile dysfunction Mechanical Diagnosis and Therapy The lower extremity Mark Miller Beata Smela Jerry Pica Richard."— Presentation transcript:

1 Reducing derangements Progressing contractile dysfunction Mechanical Diagnosis and Therapy The lower extremity Mark Miller Beata Smela Jerry Pica Richard Rosedale Guest: Karim Khan

2 MDT –The Peripheral Joints HISTORY HISTORY

3 McKenzie, R.A., The Lumbar Spine: Mechanical Diagnosis and Therapy, 1981 “With this book I present a new concept of diagnosis for the whole musculo-skeletal system.”

4 McKenzie, R.A., The Lumbar Spine: Mechanical Diagnosis and Therapy, 1981 “The procedures I developed for the lumbar spine to arrive at appropriate conclusions regarding diagnosis and treatment, may also be applied successfully to the thoracic and cervical spine, and indeed to all peripheral joints and their surrounding soft tissues.”

5 The Peripheral Joint Problem  too common  too persistent  too frustrating  current treatments  assessment reliability  assessment validity

6 The Peripheral Joint Problem (cont’d)  MRI - 32%-44% rotator cuff tears  MRI – 60% medial meniscal tears  MRI – 61.4% Knee OA abnormalities  MRI – 58% Labral lesions

7 McKenzie’s Solution Mechanical Diagnosis and Therapy Historical analysis + Mechanical assessment

8 Mechanical Diagnosis and Therapy

9 MDT and The Utah Paradigm Changing Concepts in Skeletal Physiology: Wolff’s Law, the Mechanostat, and the ‘‘Utah Paradigm’’ HAROLD M. FROST*AMERICAN JOURNAL OF HUMAN BIOLOGY 10:599–605 (1998)

10 “Biological Baseline” set at birth “Biological Baseline” set at birth Mechanical forces generate signals in skeletal Mechanical forces generate signals in skeletal tissues tissues Control the biologic mechanisms and Control the biologic mechanisms and determine the architecture and determine the architecture and strength of those tissues strength of those tissues

11 These occur in ways that let tissues These occur in ways that let tissues endure their voluntary mechanical usage endure their voluntary mechanical usage for life without hurting or breaking for life without hurting or breaking To work properly, these mechanisms need To work properly, these mechanisms need non-mechanical factors (hormones, non-mechanical factors (hormones, vitamins, calcium, etc.), vitamins, calcium, etc.), However… However…

12 Mechanical factors can guide those Mechanical factors can guide those mechanisms in time and anatomical space mechanisms in time and anatomical space This arrangement determines musculoskeletal This arrangement determines musculoskeletal health…the mechanical forces health…the mechanical forces can help or hinder can help or hinder

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14 If these mechanical factors are excessive, If these mechanical factors are excessive, inadequate or inappropriate inadequate or inappropriate Tissue weakness Tissue weakness Tissue breakdown Tissue breakdown Joint derangement Joint derangement

15 MDT Implications Use of optimum amount of mechanical load Use of optimum amount of mechanical load In the appropriate starting position In the appropriate starting position In the correct direction In the correct direction For enough time For enough time Restoration of Musculoskeletal Health

16 Extremity Examples in the Literature  A. Aina, S. May Manual Therapy 10 (2005) 159–163 (2005) 159–163 Shoulder Derangement Reduction Reduction

17 Extremity Examples in the Literature  S.J. Horton, A. Franz Manual Therapy(2007) Manual Therapy(2007) 12 (2) 12 (2) SIJ Derangement SIJ Derangement Reduction Reduction

18 Load DOES matter Become a “load master” Become a “load master” The Load Colin Davies, PT, Dip. MDT Volume 2, No. 1 March 2007 International Journal of Mechanical Diagnosis and Therapy

19 Reducing derangements Progressing contractile dysfunction Reducing derangements Progressing contractile dysfunction Mechanical Diagnosis and Therapy The lower extremity

20 Tendinopathy Degeneration Mechanotransduction

21 Stages of tissue healing Inflammatory: 1-5 days prepares area for repair prepares area for repair Inflammatory: 1-5 days prepares area for repair prepares area for repair Repair & Healing: three weeks rebuilds the structure rebuilds the structure Repair & Healing: three weeks rebuilds the structure rebuilds the structure Remodeling: up to 6 weeks-12 months provides final form of the scar provides final form of the scar Remodeling: up to 6 weeks-12 months provides final form of the scar provides final form of the scar

22 REMODELING Wolff’s law Bland’92  Bone will remodel with loading – Nordin & Frankel ’89  Muscle will hypertrophy – Pitman, Peterson ’89  Anatomical structures and tissues will tend to reflect functional stresses demanded on them

23 REMODELING  Compressed tendon was replaced by hyaline cartilage  Tension to the tendon reversed it back to the tendon structure (Merrilees & Flint 1980) In animal model:

24 Non-specific diagnosis ? “..Within physiotherapy, management is often determined by a patient’s impairment and the stage of the disorder rather than a specific tissue diagnosis…”. Jette, Delitto’97, van Baar’98, Dekker’93

25 State of tissue Pain mechanism Inflamed Normal Healing Abnormal / Contracted Abnormal / Derangement Persistent hypersensitivity Abnormal stress / mechanical Predominantly chemical Chemical/mechanical interface Mechanical Peripheral / central sensitization

26 Mechanical diagnosis  Postural  Dysfunction – articular, contractile  Derangement  Neural tissue malfunction  Other

27 Contractile dysfunction DEFINITION : Pain resulting from mechanical deformation of structurally impaired contractile tissues as a result of trauma, inflammation or degeneration.

28 Pattern based diagnosis and management INTERMITTENT PAIN  duration> than 6 weeks  PRODUCED consistently, locally  with resistive load  NO WORSE with repetition MECHANICS No immediate change with repeated resistive load on:  Range  Strength  Function

29 Management of mechanical pain Medications SHOULD Never BE THE FIRST TREATMENT CHOICE

30 Selecting resistive loading strategies

31 Spreading Localization Clear model of acceptable pain behavior in response to loading Pain lasting no longer than 10 minutes following treatment

32 Loading contractile dysfunction Active Movements Isometrics (precautions) Resisted (Concentric / Eccentric) TARGET ZONE (outer range/inner range) AmplitudeSpeed REMODEL

33 Loading/ deloading ideas  Decline board (25 degrees)  Balance board  Back pack  Weighted vest / belt  Exercise machines, t- band  Different starting positions  Assisted / deloading  Taping, straps, braces  Shoe lifts  Sound muscles - concentric, affected muscles - eccentric (Opposite leg up, affected down)  Other creative choices

34 Decline board Young 2005, Kongsgaard 2006, Visnes 2007

35 Weighted belt, vest

36 Therapeutic alliance

37 How to do it ? Loading selection YOUNG 2006 (knee)  Decline board group: 2 x daily, x 12 weeks, 60 degrees flexion, down painful leg, up on sound leg, moderate pain, back pack at 5 kg increments when pain eased 60 degrees flexion, down painful leg, up on sound leg, moderate pain, back pack at 5 kg increments when pain eased  Box squat group:as above except painful leg up/down, minimal pain, progress speed slow to fast

38 Loading selection Silbernagel 2007 (Achilles)  once a day for 6 months, reps?  on the floor to the edge of the step  two-legged concentric/ eccentric toe raises  eccentric fast rebounding toe- raises  increase repetitions  increase load ( back pack, machine)  plyometric training

39 Loading selection Alfredson (Achilles)  Eccentric loading with straight and bent knee  15 x 3set, 2 times per day for 3 months  More pain the first two weeks, the exercise must be painful

40 Loading selection McKenzie May 2003 (any contractile dysfunction at middle portion)  5-12 repetitions, 3-4 x a day at target zone progress to 10 repetitions every 2 hours progress to 10 repetitions every 2 hours produce concordant pain - no worse ( 10 min resolution following exercise) produce concordant pain - no worse ( 10 min resolution following exercise)  Force alternatives (eccentric > concentric, above/ below target zone, angle of the joint, angle of the board, external load, speed, simulate desired function

41 Return to function - timeframe 2 to 6 months

42 Barriers to recovery  Lack of early mobilization  Inadequate stress (no gradation of exercises and daily activities)  Ongoing inflammation (primature activation)  Poor timing or choice of passive modalities or orthoses  Using prolonged versus intermittent stress (Hardy ’89)  Failure to restore the desired function (especially in athletes)  Training errors (technique, plyometrics, muscle imbalances)

43 Barriers to recovery  Local steroid  Poor blood supply or ischemia, high tissue pressure with immobilization  Poor nutrition  Keloid formation or scar shortening  Nodules of abnormal tissue with nerve infiltration (Cousins ’94, Hardy)  Suspended healing  Age  Fear –avoidance, poor coping, anxiety, external locus, sick role etc.

44 Bone/tendon junction - Enthesis  Fibrocartilage enthesis  Tendon undergoes compressive forces  Poor response to tensile forces  Loading selection?

45 Outcome measures  VISA (Victorian Institute of Sport Assessment)  VISA –A (Achilles)  Lower Limb Functional Scale  Lysholm Knee Scale  VAS (Visual Analog Scale)  Functional tests: CMJ (counter movement jump) drop, vertical, max power concentric/ eccentric toe-raise, endurance test with weighted belt Other:  3 functions that are limited (rate in % of subjective recovery)

46 “ Full symptomatic recovery does not ensure full recovery of muscle –tendon function in patients with Achilles tendinopathy ”. Silbernagel KG, THomee R, Ericksson BI, KArlsson J British Journal of Sports Medicine 2007, 41

47 Special thanks

48 Group work Group work Mechanical differential diagnosis

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