Purpose
To consolidate and expand
your knowledge and skills of
Manual Therapy
Objectives
• Canadian Manual Therapy history
• Subjective examination
• Objective examination –lumbar, pelvis ,
hip,cervical , TMJ,
• Treatment approaches including
mobilizations, exercise, education and
manipulation
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
Clinical Reasoning
Hear
See
Biomedical Knowledge
Clinical Knowledge –
knowledge, skill experience
Feel
Clinical Reasoning
• The process of drawing
conclusions based upon known or
presumed facts
• Development of an accurate
diagnosis and prognosis
Hypothesis Generation
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Data collection
Interpretation of information
Cross-examination
Contributing factors
Hypothesis modification
Treatment
Reassessment
Prognosis
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
Novice
• Repertoire of clinical patterns
• Abandon checklist
• Lack experience to identify all clinical
patterns
• Often tempted to make assumption
Expert
• Need a superior knowledge base
from which to generate a high
quality hypothesis
• Clinical patterns
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
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
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
Former Paradigm
• Unsystematic observations OK
• Knowing basics OK
• Common sense enough
• Clinical experience enough
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?
New Paradigm
• Intuition- misleading
• Rationale for treatment and
discharge may be incorrect
• Understanding rules to interpret the
literature is necessary
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
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
Evidence-based Practice
“the integration of best research
evidence with clinical expertise and
patient values”
D.L. Sackett et al, 2000
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
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
Homeostasis
Restoration of
normal repair
processes facilitated
and pain is
alleviated
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
Scope of Manual Therapy
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Mobilization, Traction, Manipulation
Muscle Energy, PNF
Dynamic soft tissue release
Muscles rebalancing, muscles cocontraction
• Stabilization, Exercise Therapy
• Functional Rehabilitation
Cyriax
• Principle – “ search for physical signs ,
positive and negative and their
interpretation”
• Selective tissue tension testing
• Contractile
• Inert
Subjective
Assessment
Why is it SO Important?
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?
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
Listening is an ART:
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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)
Use our communication skill to help
patient understand……
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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
Assessment
• Subjective History
• Objective
- observation
- active – passive- resisted
• Interpretation of Evaluation
– Capsular pattern
– Resisted findings
Treatment
• Transverse frictions
• Stretch
• Manipulation
• Injections
Lower Quadrant Scan
• Rule out serious pathology
• Isolate area of dysfunction
• Identify others areas in the body
that may need attention
Observation
• Postural type
• Gross deformities
• Gait
Clearing Tests
• Squat
• Twist
• Walk (on heels and toes)
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
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
Dermatomes
• Light touch – cotton ball, kleenex
• Sharp- dull – acupuncture needle,
paper clip
S2
L5
Sensory Testing
Lower Quadrant
Hoppenfeld’76
L4
Reflexes
Achilles - S1
Quad - L3
Hamstrings - L5
Pathological Reflexes
Neg
Clonus
Pos
Babinski
Dural
• SLR
• Slump
• Prone knee bend
Articular
• SI stress test – anterior , posterior
• PA’s lumbar spine – spring tests
Perform a lower
quadrant scan
Kaltenborn
• Subjective
• Objective
– Cyriax
– Plus accessory movements
Treatment
• Hyper
• Hypo
• Restore normal glide
• Arthrokinematics – decrease capsular
tightness
Maitland Concept
Link with
• Open mind
• Logical
• Mental agility
• Methodical process
of assessing cause
and effect
• Mental discipline
Assessment
Subjective
• Provides
guidelines
• Pain patterns
Objective
• Priorize assessment
• Active, passive,
pain, resistance
• Accessory
movements
• Salient signs
• Quadrants
• Movement diagrams
Treatment
• Interpretation of evaluation
• Grading
• Techniques
• Reassess
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”
Grades of Movement
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
Evidence-based Practice
“the integration of best research
evidence with clinical expertise and
patient values”
D.L. Sackett et al, 2000
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
Systematic Reviews
Meta-analyses
Randomized Control Trials
Cohort Studies
Case Control Studies
Ideas, Editorials, Opinions
Animal research
“Best” Evidence
Clinical Expertise
The ability to use our clinical skills to
rapidly identify each patient’s
unique health state.
Patient Values
This includes a patient’s unique preferences,
concerns, and expectations as part of the
clinical decision-making and management
processes.
Treatment Today
• Outcome measure
• Improve diagnosis
• Measure ROM
• More education – ergonomics
• Patient more involved
Canadian Approach
• Recognized worldwide
• Eclectic approach
• Lamb, Morgan, Fowler, McGregor,
Oldham, Lee and many others
What must improve
• Better classification of syndromes
• Cluster of tests and treatment
approaches
• Improve reporting results of
Systematic Reviews
What will change
• Gold standards improve- MRI’s
• FCAMT’s increase in publishing
• More recognition for MT research
• Evaluate mechanisms – apply to
techniques
MSc – Orthopaedic Stream
“A new orthopaedic stream within the M.Sc.
program began in September 2002.
This program provides training in advanced manual
therapy and research methods concurrently”
Evidence – based Practice
Imperfect but necessary
Two LBP Cases
• Discuss the 2 cases
Use these headings
• Contributing Factors
• Clinical Hypothesis
• Treatment Approach
• Prognosis