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Mechanical Diagnosis & Therapy Advanced Cervical and Thoracic Spine & Extremities – Upper Limb.

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Presentation on theme: "Mechanical Diagnosis & Therapy Advanced Cervical and Thoracic Spine & Extremities – Upper Limb."— Presentation transcript:

1 Mechanical Diagnosis & Therapy Advanced Cervical and Thoracic Spine & Extremities – Upper Limb

2 Course Goals 1. Identify and discuss common problems encountered in the application of Mechanical Diagnosis and Therapy for the cervical and thoracic spine. 2. Analyse and discuss the MDT assessment and how it assists with patient classification. 3. Discuss the application of clinician forces, and how they fit with McKenzie’s ‘Progression of Forces’ concept.

3 Course Goals 4. To perform clinician techniques for the cervical and thoracic spine at an advanced level and to identify problems with their application. 5.Analyse case studies of patients presenting with cervical / thoracic symptoms and determine their classification.

4 Course Goals 6. Describe and discuss the current evidence base for the use of MDT for upper limb musculoskeletal disorders. 7.Describe the characteristics of Derangement, Dysfunction and Postural syndromes as they present in upper limb musculoskeletal disorders. 8.Perform MDT assessments for upper limb musculoskeletal disorders and determine the presence of McKenzie syndromes.

5 Course Goals 9. Design appropriate management programs for patients who present with Derangement, Dysfunction and Postural syndromes in the upper limb. with Derangement, Dysfunction and Postural syndromes in the upper limb. 10. Analyse case studies of patients presenting with upper limb symptoms and determine their classification.

6 C P R Participation Content Review About the course

7 Mechanical Diagnosis and Therapy Advanced Cervical and Thoracic Spine

8 Module One Cautions and Contra-indications

9 Review of the pre-manipulative stages in Mechanical Diagnosis and Therapy STAGE 1 STAGE 2 STAGE 3 STAGE 4 STAGE 5

10 ABSOLUTE CONTRA-INDICATIONS ABSOLUTE CONTRA-INDICATIONS Looking at the assessment forms, indicate where you would be alerted to the presence of these contra-indications

11 RELATIVE OR QUALIFIED CONTRA- INDICATIONS Looking at the assessment forms, indicate where you would be alerted to the presence of relative or qualified contra-indications

12 Cervical Arterial Disease (VBI) Cord Compression — Cervical Cauda Equina Compression Signs and Symptoms Clinical Tests Clinical Findings (with positive test) CLINICAL RECOGNITION OF CONTRA-INDICATIONS CLINICAL RECOGNITION OF CONTRA-INDICATIONS

13 Inflammatory Disorders Structural Anomalies Referred from Pathologies Elsewhere Other Cervical Spine Thoracic Spine Lumbar Spine Non-Mechanical Sources / Causes of Pain

14 Module Two Problem Areas and Problem Solving Guide Problem Areas and Problem Solving Guide

15 Problem Areas Assessment History History Physical Examination Physical ExaminationClassificationManagement Educational Component Educational Component Mechanical Component Mechanical Component

16 Problem Areas Reassessment Force Progressions Procedures Patient procedures Patient procedures Clinician procedures Clinician procedures Other problem Areas

17 Module Three Cervical Spine Workshop

18 Review Of Force Progressions Review Of Force Progressions Patient Generated Force Patient Generated Force Patient Generated Overpressure Patient Generated Overpressure Clinician Overpressure Clinician Overpressure Clinician Mobilization Clinician Mobilization Clinician Manipulation Clinician Manipulation

19 Review Of Force Progressions Review Of Force Progressions Remember: The goal of applying external force is? The goal of applying external force is? When do you add force diagnostically? When do you add force diagnostically? When do you add force therapeutically? When do you add force therapeutically?

20 Review Of Terminology Define deformity Define deformity Define lateral shift Define lateral shift Define relevant lateral shift Define relevant lateral shift Define relevant lateral derangement Define relevant lateral derangement What words describe effect during loading? What words describe effect during loading? What words describe effect after loading? What words describe effect after loading? Describe centralization pattern in the cervical/thoracic spine Describe centralization pattern in the cervical/thoracic spine

21 TABLE OF CERVICAL PROCEDURES

22 Extension Principle Procedure One - Retraction Can be performed in sitting, standing, supine, prone 1a.Retraction with patient overpressure 1a.Retraction with patient overpressure 1b.Retraction with clinician overpressure 1b.Retraction with clinician overpressure 1c.Retraction mobilisation 1c.Retraction mobilisation

23 Procedure Two - Retraction / Extension Can be performed sitting, supine, prone 2a. Retraction and extension with rotation 2a. Retraction and extension with rotation 2b.Retraction and extension with rotation and clinician traction (supine) 2b.Retraction and extension with rotation and clinician traction (supine) Procedure Three - Postural Correction

24 Lateral forces Lateral forces are considered when the sagittal plane has been exhausted. Lateral forces are considered when the sagittal plane has been exhausted. Describe what it means to exhaust the sagittal plane Describe what it means to exhaust the sagittal plane What must be found in order to consider relevant lateral? What must be found in order to consider relevant lateral? What are the typical loading strategies employed for cervical derangements with a lateral deformity? What are the typical loading strategies employed for cervical derangements with a lateral deformity?

25 Lateral Principle In the cervical spine, lateral involves either lateral flexion or rotation. In the cervical spine, lateral involves either lateral flexion or rotation. Indicate why you would choose one versus the other. Indicate why you would choose one versus the other.

26 Lateral Principle Procedure Four – Lateral Flexion Can be performed sitting, or supine 4a.Lateral flexion with patient over-pressure 4a.Lateral flexion with patient over-pressure 4b.Lateral flexion with clinician over-pressure 4b.Lateral flexion with clinician over-pressure 4c.Lateral flexion mobilisation 4c.Lateral flexion mobilisation 4d.Lateral flexion manipulation 4d.Lateral flexion manipulation

27 Lateral Principle Procedure Five – Rotation Can be performed sitting or supine 5a.Rotation with patient over-pressure 5a.Rotation with patient over-pressure 5b.Rotation with clinician over-pressure 5b.Rotation with clinician over-pressure 5c.Rotation mobilisation 5c.Rotation mobilisation 5d.Rotation manipulation 5d.Rotation manipulation

28 Flexion Principle Procedure Six – Flexion Can be performed sitting or supine 6aFlexion with patient over-pressure 6aFlexion with patient over-pressure 6bFlexion with clinician over-pressure (supine) 6bFlexion with clinician over-pressure (supine) 6cFlexion mobilisation (supine) 6cFlexion mobilisation (supine)

29 Recovery of Function What is evidence of full reduction? What is evidence of full reduction? When to and how to test for recovery of function? When to and how to test for recovery of function? Is it necessary to recover function in the cervical spine? Is it necessary to recover function in the cervical spine?

30 Differential Diagnosis Cervical Derangement Cervical Adherent Nerve Root Shoulder Pathology Pain location Constant or Intermittent Aggravating factors Easing factors Movement Loss Response to cervical repeated movements Other tests

31 Upper cervical spine Self-treatment procedures for the upper cervical spine are: Self-treatment procedures for the upper cervical spine are: Retraction Retraction Flexion Flexion Rotation Rotation Combination flexion / rotation Combination flexion / rotation Combination extension / rotation Combination extension / rotation

32 Module Four Thoracic Spine Workshop

33 Thoracic Spine Do not assume that symptoms arise from the thoracic spine simply based on location of symptoms. Do not assume that symptoms arise from the thoracic spine simply based on location of symptoms. Cloward 1950 demonstrated that structures in the lower cervical spine could refer to the lower angle of the scapula. Cloward 1950 demonstrated that structures in the lower cervical spine could refer to the lower angle of the scapula. The actual incidence of true thoracic problems is quite low. The actual incidence of true thoracic problems is quite low. Look for clues in the history. Look for clues in the history.

34 Thoracic Spine Rule out cervical/lumbar involvement before examining the thoracic spine. Rule out cervical/lumbar involvement before examining the thoracic spine. Attempt to target loading to the thoracic spine while minimizing load in the lumbar/cervical. This may be accomplished through attention to detail with the thoracic techniques. Attempt to target loading to the thoracic spine while minimizing load in the lumbar/cervical. This may be accomplished through attention to detail with the thoracic techniques. The thoracic spine will often require higher levels of force such as over-pressure, mobilization, and sustained loading. The thoracic spine will often require higher levels of force such as over-pressure, mobilization, and sustained loading.

35 Thoracic Spine What sub-classifications are rarely seen in the thoracic spine? What sub-classifications are rarely seen in the thoracic spine?

36 Table of Thoracic Procedures

37 Extension Principle Procedure One ‑ Extension Can be performed sitting (mid thoracic), supine (upper thoracic), prone (mid and lower thoracic). Can be performed sitting (mid thoracic), supine (upper thoracic), prone (mid and lower thoracic). 1a.Extension with patient over-pressure 1a.Extension with patient over-pressure 1b.Extension with clinician over-pressure 1b.Extension with clinician over-pressure 1c.Extension mobilisation 1c.Extension mobilisation 1d.Extension manipulation in prone 1d.Extension manipulation in prone

38 Extension Principle Procedure Two ‑ Posture Correction Procedure Two ‑ Posture Correction

39 Lateral Principle Procedure Three ‑ Rotation 3a.Rotation with patient over-pressure 3a.Rotation with patient over-pressure 3b.Rotation with clinician over-pressure 3b.Rotation with clinician over-pressure 3c.Rotation mobilisation in sitting or in prone 3c.Rotation mobilisation in sitting or in prone 3d.Rotation manipulation in prone 3d.Rotation manipulation in prone

40 Flexion Principle Procedure Four ‑ Flexion 4a.Flexion with patient over-pressure 4a.Flexion with patient over-pressure

41 Module Five Reflective learning

42 Module Six Case Studies

43 MECHANICAL DIAGNOSIS AND THERAPY EXTREMITIES – UPPER LIMB

44

45

46 Module Seven: Epidemiology / Evidence Base for MDT in the Upper Limb

47 Site of the problems – % general population (Badley 1992) Site of the problems – % general population (Badley 1992)

48 Site (N = 522)

49 Evidence Base for MDT in the Upper Limb Surveys of: Surveys of: Prevalence rate of mechanical syndromes in extremity patients Prevalence rate of mechanical syndromes in extremity patients 27% derangement 27% derangement Prevalence rate of derangement varied quite widely across different surveys and different joint sites. Prevalence rate of derangement varied quite widely across different surveys and different joint sites.

50 Evidence Base for MDT in the Upper Limb Two surveys have assessed reliability Pilot study using 11 patient vignettes and 3 Credentialed therapists there was 82% agreement with a kappa value of 0.70 (Kelly et al 2008). Pilot study using 11 patient vignettes and 3 Credentialed therapists there was 82% agreement with a kappa value of 0.70 (Kelly et al 2008). 25 patient vignettes and 97 therapists with MDT diploma status worldwide there was 92% agreement, with a kappa value of 0.83. (May and Ross 2009). 25 patient vignettes and 97 therapists with MDT diploma status worldwide there was 92% agreement, with a kappa value of 0.83. (May and Ross 2009).

51 Evidence Base for MDT in the Upper Limb Evidence Base for MDT in the Upper Limb Case Studies Shoulder derangement, (Aina and May 2005). Shoulder derangement, (Aina and May 2005). Shoulder contractile dysfunction, (Littlewood and May 2007). Shoulder contractile dysfunction, (Littlewood and May 2007). Thumb derangement. (Kaneko et al. 2009). Thumb derangement. (Kaneko et al. 2009).

52 Module Eight Characteristics of the Three Syndromes

53 MDT at the shoulder – 3 surveys with 134 shoulder patients total (%)

54 Shoulder mechanical syndromes (N = 116)

55 Three Syndromes Operational Definition Derangement - lasting abolition or decrease of symptoms, and/or an increase in restricted range of movement in response to repeated movements. Derangement - lasting abolition or decrease of symptoms, and/or an increase in restricted range of movement in response to repeated movements.

56 Three Syndromes Operational Definition Articular dysfunction - intermittent pain consistently produced at a restricted end-range with no rapid change of symptoms or range. Articular dysfunction - intermittent pain consistently produced at a restricted end-range with no rapid change of symptoms or range. Contractile dysfunction - intermittent pain, consistently produced by loading the musculotendinous unit, for instance with an isometric contraction against resistance. Contractile dysfunction - intermittent pain, consistently produced by loading the musculotendinous unit, for instance with an isometric contraction against resistance.

57 Three Syndromes Operational Definition: Postural syndrome - only produced by sustained loading, which once avoided, the rest of the physical examination would be normal. Postural syndrome - only produced by sustained loading, which once avoided, the rest of the physical examination would be normal.

58 Other Operational Definition ‘Other’ refers to failure to classify as one of the above mechanical syndromes. ‘Other’ refers to failure to classify as one of the above mechanical syndromes. eg recent trauma, post-surgery or chronic pain state. eg recent trauma, post-surgery or chronic pain state.

59 Shoulder (N = 157)

60 MDT at the shoulder – 3 surveys with 134 shoulder patients total (%)

61 Shoulder mechanical syndromes (N = 116)

62 DerangementArticular Dysfunction Contractile Dysfunction Posture State Status Const/Intermittent Chemical Component Movement Loss Response during loading Response after loading Prognosis

63 Module Nine Assessment

64 Problem Areas History History Physical Examination Physical Examination Active movements Passive movements (+/- over-pressure) Resisted movements Repeated movements Sustained postures.

65 The Response to Repeated Movements Implication No pain during repeated movements. Pain produced only at limited end ‑ range, no worse afterwards. Pain produced only by resisted tests, no worse afterwards. Increasing symptoms in one direction, decreasing symptoms in the other. All directions cause lasting increase in pain in sub-acute condition. Persistent pain in which initial active therapy causes some temporary aggravation of symptoms.

66 Assessment Keep an open mind. Keep an open mind. Do not assume that the diagnosis provided, the imaging findings, or the patient’s beliefs are correct. Do not assume that the diagnosis provided, the imaging findings, or the patient’s beliefs are correct. Ensure to clear the spine – assume spine first then chase extremity disorder. Ensure to clear the spine – assume spine first then chase extremity disorder. Check baselines in both areas. Check baselines in both areas. Remember to achieve end range and alter the load. Remember to achieve end range and alter the load. If inconclusive test over 2/3 days. If inconclusive test over 2/3 days.

67 Module Ten Derangement Syndrome

68 Derangement Key features of Derangement from the assessment Key features of Derangement from the assessment 1. 1. 2. 2. 3. 3. 4. 4.

69 Therapeutic management Consists of: Educational component Educational component Active mechanical therapy component. Active mechanical therapy component.

70 Education Component Information about the problem itself; Information about the problem itself; What patients can do to help themselves; What patients can do to help themselves; Information about tests, diagnosis and interventions; Information about tests, diagnosis and interventions; An idea about the prognosis of the problem. An idea about the prognosis of the problem.

71 Education Component Patient education should not be seen as a ‘nice extra’, but as an effective treatment in itself. but as an effective treatment in itself.

72 Active Mechanical Therapy Component Active Mechanical Therapy Component Following an explanation of the role of the exercise: Specific exercises should be demonstrated to the patients, Specific exercises should be demonstrated to the patients, They should practice these, They should practice these, Expected pain response should be explained, Expected pain response should be explained,

73 Active Mechanical Therapy Component Active Mechanical Therapy Component Exercises should be repeated 10 times 3 or 4 times a day, initially Exercises should be repeated 10 times 3 or 4 times a day, initially Can be done every 2 hours once response clear Can be done every 2 hours once response clear Progressions and force alternatives should be used. Progressions and force alternatives should be used.

74 Empowerment Active self-management rather than compliance is the preferred outcome (Brady 1998). Active self-management rather than compliance is the preferred outcome (Brady 1998). Can be achieved if the patient is sufficiently informed and empowered. Can be achieved if the patient is sufficiently informed and empowered. It is the therapist’s responsibility to try to create this state of mind. It is the therapist’s responsibility to try to create this state of mind.

75 Derangement Syndrome  Repeated Reductive Movement  Avoidance of aggravating factor

76 Direction specific exercises (May 2006)

77 Progression of forces that may be used in the management of derangements: 1. 1. 2. 2. 3. 3. 4. 4. 5. 5.

78 Common Upper Extremity Derangements Shoulder Shoulder Elbow Elbow Wrist Wrist

79 Module Eleven Dysfunction Syndrome

80 Dysfunction Key features of Articular Dysfunction from the assessment Key features of Articular Dysfunction from the assessment 1. 1. 2. 2. 3. 3. 4. 4.

81 Articular Dysfunction: end-range repeated loading Education in Self Management Education in Self Management Self-treatment procedures Self-treatment procedures

82 Common Upper Extremity Articular Dysfunctions Shoulder Shoulder Elbow Elbow Wrist Wrist

83 Contractile Dysfunction Key features of Contractile Dysfunction from the assessment 1. 1. 2. 2. 3. 3. 4. 4.

84 Contractile Dysfunction Education in Self Management Education in Self Management Self Treatment Self Treatment  Repeat mid-range loading  Use of Target Zone  Use of Eccentric loading

85 Why is loading therapeutic? ‘Mechanotransduction’ - Turning Movement into repair - Turning Movement into repair Cells convert mechanical signals into biochemical responses, Cells convert mechanical signals into biochemical responses, Physiological - adjusts structure to demand Physiological - adjusts structure to demand Non-neural communication (gap junctions) Non-neural communication (gap junctions)

86 So how does one prescribe that ‘optimal load’ Excessive load – injures tendon Under-load – no stimulus for repair Optimum load – stimulates healing

87 Where to start the loading ? Start with what is tolerable and functionally relevant. Start with what is tolerable and functionally relevant. Symptom response should be P, NW Symptom response should be P, NW Remember to progress forces and use force alternatives Remember to progress forces and use force alternatives

88 Force Options  Active Movements  Static / isometric  Resisted  Concentric / Eccentric  Outer range/inner range/mid range  Amplitude  Speed

89 A few RCTs Brox et al (1999) 125 patients with chronic RC disease Brox et al (1999) 125 patients with chronic RC disease 1-2 years duration failed to improve with ‘physio’ NSAIDs etc 1-2 years duration failed to improve with ‘physio’ NSAIDs etc 1 = arthroscopy1 = arthroscopy 2 = resisted exercises2 = resisted exercises 3 = placebo laser3 = placebo laser Neer scores (1&2 SD 3) Neer scores (1&2 SD 3)

90 Haahr et al (2005) 90 patients with RC disease – majority > 1year Haahr et al (2005) 90 patients with RC disease – majority > 1year 1 = arthroscopy1 = arthroscopy 2 = strengthening exercises2 = strengthening exercises Constant score (NS) Constant score (NS)

91 Jonsson et al 2006 9 patients with chronic impingement (mean 41 months) on surgical waiting list. 9 patients with chronic impingement (mean 41 months) on surgical waiting list. Lots of previous treatment. Lots of previous treatment. Treated with progressive eccentric training for supraspinatus and deltoid. Treated with progressive eccentric training for supraspinatus and deltoid. 15-20 point improvement in mean VAS Constant score 15-20 point improvement in mean VAS Constant score 5/12 withdrew from surgical waiting list. 5/12 withdrew from surgical waiting list.

92 Jonsson et al 2006 Ulla –sling used to elevate arm, 30 degrees of horizontal abduction. Eccentric work achieved by lowering the arm.

93 Jonsson et al 2006 End position for eccentric exercise Progression by adding weight

94 Module Twelve Postural Syndrome

95 Key features of Postural Syndrome from the assessment Key features of Postural Syndrome from the assessment 1. 1. 2. 2. 3. 3. 4. 4.

96 Postural Syndrome Education towards self-management Education towards self-management Interruption of aggravating posture Interruption of aggravating posture Ergonomic interventions Ergonomic interventions Prevention easier than treatment Prevention easier than treatment

97 Postural Syndrome Postural syndromes seen in the upper extremities ?

98 Module Thirteen Case Studies


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