Chapter 1: Specific Interventions

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dmshaw9
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Chapter 1: Specific Interventions
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2015-03-03 22:32:44
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Specific Interventions
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NPTE Chapter 1
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  1. Soft Tissue/Myofascial Techniques: Purpose
    • Aid in reduction of of metabolites from muscle
    • Reactivating a muscle that has not been functioning secondary to guarding and ischemia
    • Revascularization of muscle
    • Decrease guarding in a muscle
  2. Soft Tissue/Myofascial Techniques: Autonomic Effects
    Stimulation of skin and superficial fascia to facilitate decrease in muscle tension
  3. Soft Tissue/Myofascial Techniques: Mechanical Effects
    • Movement of skin, fascia, and muscle causes histological and mechanical changes to occur in soft tissues
    • Produces improved mobility and function
  4. Soft Tissue/Myofascial Techniques: Goals
    • Decrease pain, edema and muscle spasm
    • Increase metabolism and cutaneous temperature
    • Stretch tight muscles and other soft tissues
    • Improve circulation
    • Strengthen weak muscles
    • Mobilize joint restrictions
  5. Soft Tissue/Myofascial Techniques: Indications
    Patients withs oft tissue and joint restriction that result in pain and limit ADL's
  6. Soft Tissue/Myofascial Techniques: Contraindications
    • Absolute: soft tissue breakdown, infection, cellulitis, inflammation, and/or neoplasm
    • Relative: hypermobility and sensitivity
  7. Soft Tissue/Myofascial Techniques: Types
    • Effleurage
    • Petrissage
    • Functional massage
    • Transverse friction massage
    • Movement approaches
  8. Functional Massage
    • Three techniques used to assist in reactivation of debilitated muscle and/or to increase vascularity to a muscle
    •  
    • 1) Soft tissue without motion
    • 2) Soft tissue with passive pumping
    • 3) Soft tissue with active pumping
  9. Functional Massage: Soft Tissue Without Motion
    • Traditional technique 
    • Hands do not slide over skin -- stay in contact with skin while hands and skin move together over muscle
    • Direction of force is parallel to muscle fibers 
    • Total stroke time should be 5-7 seconds
  10. Functional Massage: Soft Tissue with Passive Pumping
    • Place muscle in shortened position and one hand place tension on muscle parallel to muscle fibers 
    • Other hand passively lengthens muscle and simultaneously gradually releases tension of hand in contact with muscle
  11. Functional Massage: Soft Tissue with Active Pumping
    • Place muscle in lengthened position 
    • With one hand, place tension on muscle perpendicular to muscle fibers
    • Other hand guides limb as pt actively shortens muscle
    • As muscle shortens, gradually release tension of hand in contact with muscle
  12. Transverse Friction Massage
    • Used to initiate an acute inflammatory response for a tissue that is in metabolic stasis (i.e. tendonosis)
    • Involved tendon is briskly massaged in transverse fashion (perpendicular to direction of fibers)
    • Performed for 5-10 minutes and tends to be very uncomfortable for the pt
  13. Movement Approaches
    Require the patient to actively participate in treatment

    • Examples include:
    • 1) Feldenkrais
    • 2) MET
    • 3) PNF Hold-Relax-Contract Technique
  14. Feldenkrais Technique
    • Facilitates development of normal movement patterns
    • Practitioner uses skillful, supportive gentle hands to create sense of safety, maintain supportive contact, while introducing new movement possibilities in small, easily available increments
  15. Muscle Energy Techniques (MET)
    • Include voluntary contraction in a precisely controlled direction, at varying levels of intensity, against an applied counterforce from clinician
    • Purpose is to gain motion that is limited by restrictions of neuromuscular system
    • Modification of PNF technique
  16. PNF Hold-Relax-Contract Technique
    Antagonist of shortened muscle is contracted to achieve reciprocal inhibition and increased range
  17. Joint Oscillations: Purpose
    • Inhibit pain and/or muscle guarding
    • Lubricate joint surfaces
    • Provide nutrition to joint structures
    • Maitland suggests that grades III and IV oscillations are beneficial to stretch tight connective tissues
  18. Five Grades of Joint Play in Neutral
    • Grade I: small amplitude, at beginning of range of joint play
    • Grade II: large amplitude, midrange of joint play
    • Grade III: large amplitude, at ends range of joint play
    • Grade IV: small amplitude at end range of joint play
    • Grade V: manipulation of high velocity and low amplitude to anatomical endpoint of a joint (technically not an oscillation, since it is a single movement rather than a repetitive one)
  19. Indications for Use of Oscillation Grades (per Maitland)
    • Grades I and II: improve joint lubrication and nutrition, decrease pain and muscle guarding
    • Grades III and IV: stretch tight muscles, capsules, and ligaments
    • Grade V: regain normal joint mechanics as well as decrease pain and muscle guarding
  20. Contraindications for Joint Oscillation/Mobilization/Manipulation: Absolute
    • Joint ankylosis
    • Malignancy involving bone
    • Disease that affect integrity of ligaments (RA and Downs)
    • Arterial insufficiency
    • Active inflammatory and/or infective process
  21. Contraindications for Joint Oscillation/Mobilization/Manipulation: Relative
    • Arthrosis (DJD)
    • Metabolic bone disease (osteoporosis, Paget's disease, and tuberculosis)
    • Hypermobility
    • Total joint replacement
    • Pregnancy
    • Spondylolisthesis
    • Use of steroids
    • Radicular symptoms
  22. Joint Mobilization (Nonthrust): Purpose
    To stretch/lengthen/deform collagen and normalize arthrokinematic glide (as described by Kaltenborn

    • Grade I:
    • "Loosening" translatoric glide
    • Small amplitude traction force
    • Relieve pain and/or decompress joint during joint glides

    • Grade II:
    • "Tightening" translatoric glide
    • Movement takes up slack in tissues surrounding joint
    • Used to alleviate pain, assess joint play, and/or reduce muscle guarding

    • Grade III:
    • "Stretching" translatoric glide
    • Movement stretches tissues crossing the joint 
    • Used to assess end-feel or to increase movement (stretch tissue)
  23. Traction
    • Mechanical, manual, and self or auto traction
    • Vertebral bodies separating
    • Distraction and gliding of facet joints
    • Tensing of ligamentous structures of the spinal segment
    • Intervertebral foramen widening
    • Spinal muscles stretching
  24. Manipulation (Thrust): Purpose
    • Inhibit pain and/or muscle guarding
    • Improve translatoric glide in cases of joint dysfunction due restriction
    • Health care practitioners who perform include PTs, osteopaths, chiropractors, and medical doctors
  25. Manipulation (Thrust): Types
    • Generalized: 
    • Fairly forceful
    • Long lever techniques intended to include as many vertebral segments as possible
    • More commonly performed by chiropractic practitioners 

    • Specific:
    • Aimed at having an effect on either a specific segment or only a few vertebral segments
    • Minimal force with sort lever arm
    • Often includes "locking" techniques based on biomechanics to ensure that a specific vertebral segment receives the manipulative thrust
    • More commonly performed by PTs

    • Mid-Range:
    • Very gentle, short lever arm techniques
    • Barrier created in mid-range by specific positioning of patient as well as creating tautness in surrounding soft tissues
    • More commonly performed by osteopathic practitioners
  26. Common Mistakes in Performing Thrust Manipulation
    • Not communicating clearly with pt regarding the technique
    • Taking too long to properly position the pt
    • Not performing "trial" thrust prior to actual thrust
    • Not allowing person to bottom out with breath prior to performing thrust
    • Taking up slack while pt exhales and then letting off with pressure prior to thrust
    • Velocity too slow
    • Amplitude too great 
    • Headaches in cervical region are common indication for thrusts but also a contraindication (ask about birth control combined with smoking since this may be a cause for a vascular accident - HA frequently precede CVA)
    • Consider performing thoracic thrusts to attain result that was sought after for cervical thrust 
    • Perform vertebrobasilar testing when performing manipulations to cervical segments
  27. Neural Tissue Mobilization
    • Movement of neural structures to regain normal mobility
    • Tension tests for upper and lower extremities (i.e. dural stretch tests) = movement of soft tissues that may be restricting neural structures (i.e. cross friction massage for adhesions of radial nerve to humerus at fracture site) 
    • Perform assessment with neurotension testing
    • Determine whether managing irritated or non irritated neurological tissue (irritated - grade II mobs (Maitland) - should be non painful; non irritated - grade III mobs (Maitland) to engage barrier but remain non painful)
    • Postural reeducation: to open up interverebtral foramen and decrease tension to tissues
  28. Upper and Lower Extremity Neural Tension Tests: Indications and Contraindications
    • Indications: used for pts who have some type of restriction in neural mobility (anywhere along course of nerve)
    • Contraindications: extreme pain and/or increase in abnormal neurological signs
  29. Indications for Therapeutic Exercise
    • Decrease muscle guarding
    • Decrease pain
    • Increase vascularity of tissue
    • Promote regeneration and/or speed up recovery of connective tissues (cartilage, tendons, ligaments, capsules, and intervertebral discs)
    • Mobilize restricted tissue to increase flexibility
    • Increase endurance of muscle
    • Increase coordination of muscle
    • Increase strength of muscle
    • Sensitize muscle to minimize joints going into excessive range (in cases of hyper mobility)
    • Develop dynamic stability and functional movement patterns, allowing for optimal function within the environment
  30. Home Exercise Program
    • Pt's home program will consist of exercises to reinforce clinical program
    • Necessary to perform enough reps for desired physiological effete on appropriate tissues as well as develop coordination and endurance to promote dynamic stability within functional patterns
  31. Dry Needling
    • A.K.A. Intramuscular Manual Therapy (IMT)
    • Utilized to break up TPs in myofascial pain syndrome 
    • Solid filiform needle is inserted into trigger point (within the muscle)

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