A few weeks back Chris wrote a great post on Sequencing Your Treatment Session. His post focused heavily on manual treatment and the importance of checking and rechecking your asterisk (concordant) sign. This post is intended to be a quick and dirty outline regarding how to prioritize interventions from start to finish. Not all apply to every patient, but knowing the sequence is fundamental.

1) Brief Subjective/Objective Recheck: This should be viewed as a mini-reassessment. Was there any change in symptoms since their last visit? How did they tolerate the their HEP? How did the patient respond 24-hours after the last treatment? Objectively, are the same restrictions and movement impairments present?
2) Manual Therapy: During the objective, you likely found a joint restriction or movement pattern that needs correcting. Perform the necessary manual techniques and re-check your asterisk sign. 
3) Corrective Exercise: Performing corrective exercises immediately following manual therapy will maximize the patient's ability to find and recruit muscles that were previously not recruiting normally.
4) Functional Warm-up: The warm-up should increase core temperature targeting the muscle groups that are dysfunctional. Examples: bicycle, total gym, elliptical. 
5) Power Exercises: Incorporate power/ plyometric exercises following the warm-up when the muscles are not fatigued. Since form is essential during these exercises, performing them while the muscles are fresh is very important. It should be noted that not all patients will be ready for power-type exercises during their first few visits.
6) Strength Exercises: Strength exercises include those performed in the 4-8 repetition range, 3-4 sets with 2-3 minutes of rest between each set. Similar to power, not all patients can tolerate pure strengthening early on. Many times patients require a few sessions of neuromuscular re-education and form re-training prior to pure strengthening.
7) Conditioning and Endurance: Often we find ourselves going directly to this stage following a functional warm-up. Since pain and movement impairments our the primary focus early on, performing conditioning or retraining exercises is acceptable. The dosage of these exercises is typically 3 sets of >10 repetitions with less rest in between sets. A main focus is on proper form and controlling the movement throughout the ROM.  
8) Warm Down

Appropriately structuring a treatment session is a key component to the patient's success. One question you need to continually ask yourself: "how do you dose pain?" There is no perfect answer. Pain generally leads to muscle inhibition and form breakdown which often categorizes the patient in the conditioning and retraining exercises section. As your patient progresses it is essential to perform the exercises in an appropriate order to maintain form and maximize gains throughout the session. 

-Jim  

The last month or so I have been using repeated motions consistently in my evaluations and treatments. Like many other PT's, I was taught McKenzie in school basically was lumbar extensions and only applied to a select few patients. The misunderstanding of how repeated motions work and should apply to our patients is probably one of the most significant disservices we are doing to our patients. Since incorporating them into my care (thanks to The Manual Therapist), I have noted significantly greater improvements in less time. Now I do not have a full understanding of the system based on MDT, but this post will link to several posts by The Manual Therapist so you can learn to apply it tomorrow.

Let's start of with why you should be using repeated motions in your exam. With about 90% of our patients being rapid responders, we should be getting immediate improvements on the day of our examination. Repeated motions are easy, reliable, have built in testing, lead you to treatment and give you your HEP. You will notice with application of these principles, for the appropriate patient you will be amazed at how much better your patients get faster.

Now what exactly is that about MDT and repeated motions that makes it so effective. Let's start with some of the misconceptions about MDT. MDT does benefit from some manual techniques. While I like repeated motions because it makes the patient more independent and gives them their HEP, sometimes they are unable to get the patient 100% of the way there. A manual technique may get that extra bit or may even accelerate improvements in another area. The MDT theory is not based on disc model like what is taught in school. With modern pain science showing how much force is required to deform tissues and how much normal degeneration solidifies different tissues, we must realize that we are not actually affecting the disc. These "disc" injuries are often associated with McKenzie extension exercises, leading to the stereotype that MDT is extension. This couldn't be further from the truth as repeated motions can be applied to any direction and any joint (the link there has a video that shows various resets for repeated motions at different joints). So how are the changes acquired with MDT? One of the prime components of why MDT works (per one hypothesis) is because the repeated loading of the joints engages mechanoreceptors enhancing proprioception. This may alter the patient's perception of their ability to go into what was a painful motion.

What is necessary for repeated motions to actually work is to actually get to end range. We all have seen mobilizations and manipulations have improvements with our patients. There are different theories as to how these changes actually occur, but one of the necessary components is that end-range is required. Repeated motions have the benefit of making the patient independent with their care and allows a patient to maintain any gains acquired from PT. We may not improve ROM in all patients due to degeneration, but pain or other symptoms can still improve. It is often difficult for patients to get to this end-range out, because more often than not the direction that is prescribed is the painful one. With each motion in the correct direction, the patient will realize that it is okay to move into that direction and lower their fear avoidance.

How do we choose which direction to proceed? The treatment choice is based on the directional preference. The directional preference is the direction that a joint needs to be repeatedly loaded to have effects potentially on ROM, pain, DTR's, strength, and function. The direction is more often than not the direction the patient tends to avoid. When trying to find the directional preference for sure or when distributing a repeated motion as part of an HEP, it is essential that you remember the stoplight system. The stoplight system allows you and the patient to monitor the progress of symptoms ensuring the correct exercise was given. A green light is when the symptoms centralize and remain better. It is still a green light if the pain centralizes but increases centrally, because it is still centralizing! A yellow light is when a patient's pain or symptoms increases but they can "walk it off." What we must realize with yellow lights is that maybe a patient's pain will increase, but in doing so they have greater motion or greater motion before the pain occurs. It is easy to become hesitant with yellow light responses, but we must remember that we need to get to end-range to have the desired effect. A red light is when a patient's pain or symptoms worsen but cannot be "walked off."

Hopefully this helps to summarize some of the concepts of repeated motions and MDT. I encourage you to look at each one of the links for further information and better understanding of repeated motions. For more information, check back on Dr. E's blog regularly in order to enhance your understanding in the area. He often has posts like this that may show you how to incorporate MDT into your clinical reasoning. In doing so, you likely will notice rapid improvements with many of your patients.

-Chris

A couple months ago, we were sent some samples of orthopaedic texts to review. Having come from a program where no real orthopaedic text books were issued, we were very interested in the opportunity to see what Prohealth had to offer. Given our backgrounds now as residency-trained therapists, we also can add some additional perspective on what is essential for orthopaedic texts. The books included in our review are: Muscle Manual, Spinal Manual, Extremity Manual, Orthopaedic Conditions, Physical Medicine, and Physical Assessment.

The Muscle Manual is an equivalent of what the famous Florence Kendall presented in her texts. However, the Muscle Manual offers much more than Kendall in other areas. Not only does this book include origin, insertion, action, innervation, blood supply, muscle strength test, or muscle length test, the book also offers anatomic variations, common injuries, palpation technique, trigger point referral, methods to strengthen and stretch the muscle. These additions have pretty significant clinical implications. Now with all that being said, in our opinion the book is lacking in detail of the muscle attachment sites. The importance of this is debatable as with all the anatomical variations, the need for exact specifications for each muscle (i.e. "the anterolateral surface of the proximal portion...") may be less significant.

The next couple books go hand in hand: Spinal Manual and Extremity Manual. These probably compare with most of the orthopaedic text books on the market that schools are aware of. Each book is divided into joint-based sections (i.e. cervical spine, shoulder, etc). At the beginning of each sections, there is a review of anatomy, kinesiology, ROM, MMT and exam flow for the joint. The section then leads into a breakdown of each common pathology for the joint. These breakdowns include: basic information, classification, demographics, history, physical exam findings, a multi-disciplinary treatment approach, and prognosis. This can be beneficial considering how often we are asked about different treatment approaches for each pathology (acupuncture, medications, diet and botanicals, etc. As we move towards a more connected health care system, this will be essential in providing our patients the best care. The books also contain an opening that includes a breakdown of how subjective histories should be taken, how to analyze articles, systems review, differential diagnosis, gait cycle, and more. These inclusive text books can be extremely beneficial for those trying to figure out proper exam flow and may be good references for the boards or OCS exam. Unfortunately, these texts are lacking in movement analysis. Like most orthopaedic text books, a pathological approach is taken that primarily involves treating the symptomatic tissues, not the cause of the symptomatic tissue. Leaving out subjects like Sahrmann's movement impairment syndromes or other methods of movement analysis prevents many from treating the original cause of the problem. However, these texts would still stand as excellent references for a condition and possibly various evidence-based treatment approaches.

Prohealth also offers an Orthopedic Conditions text which is packed with useful information regarding assessment, diagnosis, and management of Orthopedic conditions. Under each diagnosis section, information is included on history, physical exam, differential diagnosis, special tests, diagnostic imaging, and laboratory tests. Having the imaging and laboratory tests included in the diagnosis is extremely helpful. For example, when reading about the scaphoid fracture, Dr. Vizniak includes an X-ray, T1 MRI, and T2 MRI images to show the differences between each image. At the end of the book, he includes a Key Movement Patterns (KMP) section outlining common movement patterns that occur in response to poor posture or pain. It is not as in depth as a Sahrmann type movement impairment syndromes, but it is a great quick guide to assessing for movement dysfunction. We can honestly say that the Orthopedic Conditions book is an excellent evidenced informed guide to helping manage musculoskeletal conditions.   

For more specific treatment techniques, the Physical Medicine text may prove useful. The book includes a joint-by-joint breakdown of various treatments and assessments. Methods of mobilization, manipulation, MET's, STM, strengthening and stretching are included for each joint. Additionally, taping, electrotherapy, acupuncture, and nutrition are covered. This may prove useful as a reference for those looking for a taping technique, a suggestion for herbal supplements, different manual techniques and more. While no substitute can be made for actual practice and learning with the instructor of manual techniques, this book allows one to review the various methods of treatment and assessment with ease. The Physical Assessment book is useful for various examination techniques and special tests. It includes images, descriptions and diagnostic accuracy for the tests.

While these texts may not represent the movement towards a kinesiopathology approach for physical therapy, they definitely play a role as references for the clinic for specific pathologies, assessment, treatment, and anatomy in general. The global approach each text provides in developing the clinical reasoning of the reader can be an incredible component to the growth of a professional. Additionally, each book has links to videos on the website that provides an alternative learning method and supplementary information. Check out on the website for more information for these books.

In the March 2014 edition of the Physical Therapy Journal, Shirley Sahrmann wrote a perspective paper regarding our role as movement specialists. Her paper was written in response to the 2013 APTA House of Delegates new vision statement, "transforming society by optimizing movement to improve the human experience." A key guiding principle of that vision statement is that "the physical therapy profession will define and promote the movement systems as the foundation for optimizing movement." 

Sahrmann states several purposes of the paper, two of which I am going to elaborate on in this post:
1. Advocate for promoting both kinesiopathology and pathokinesiology as important movement system concepts 
2. The movement system must be embraced by physical therapists who seek to achieve the full potential of their critically important role in society. 

1. Advocate for promoting both kinesiopathology and pathokinesiology as important movement system concepts 
Without question, movement is at the heart of the physical therapy profession. In a sense, it is our identity. This message has been proclaimed for decades, most notably by Florence Kendall who throughout her career discussed "the importance of the profession establishing a relationship with a system of the body." However, if movement is truly what we do, we need to start promoting a model that reflects our practice. These models are both pathokinesiology and kinesiopathology.     

By promoting pathokinesiology and kinesiopathology, we are intentionally moving away from the standard pathoanatomical model. Rotator cuff tear, disc herniation, trochanteric bursitis, etc. will not be the focus of our treatments as they do not incorporate the underlying movement dysfunction. For example, a person with a referring dignosis of disc herniation might actually have a disc herniation, but that is not what we are treating. Our job is to treat the movement pattern that is causing that person's symptoms. The cause of their disc herniation could be due to poor proximal strength, adverse neural tension, poor lumbopelvic disasociation, or others. Documenting in your assessment that the patient has a disc herniation provides no explanation for the type of physical therapy treatment you intend to perform. This is a difficult concept to fully grasp as much of PT school and the APTA are still focused on the anatomy of the pathology. If you look at the Orthopaedic Section's monographs, most of the content is broken down by pathology: osteoarthritis, tendinopathy, impingement, etc. If we are going to identify ourselves as movement specialists, we need to begin moving away from pathoanatomical terms and starting speaking the language of pathokinesiology. We are not treating the anatomy, we are treating the underlying movement dysfunction. 

2. The movement system must be embraced by physical therapists who seek to achieve the full potential of their critically important role in society. 

If we are not treating the anatomy and we are focusing on the movement dysfunction, we need to start identifying ourselves with a specific movement system. The system needs to be universal and recognized by all individuals that practice it. Current systems I have been exposed to are the Sahrmann movement impairment systems and the Selective Functional Movement Assessment (SFMA). Both of these systems focus on identifying the cause of the cause of a patient's symptoms.. For example a patient with a rotator cuff tear may present as a Sahrmann shoulder downward rotation syndrome. Using the SFMA, they could be classified as dysfunctional painful (DP) in the shoulder patterns. Both systems would likely find the primary impairments as weak lower traps, weak serratus anterior, strong downward rotators, and poor thoracic mobility depending on how the patient presents. The impairments were found by analyzing movement and help guide the therapist in his or her diagnostic process.  

Adopting a movement system will standardize our treatment programs, improve outcomes, and help us reach autonomy. As Sahrmann states in her perspective paper, "if we are able to successfully define the components of the movement system such that they can be reliably tested and validly treated, we will be illuminating that area of human function and be recognized for that expertise." 

I want to conclude with another Sahrmann quote:
""Labeling a condition is most often the first step in treatment. Referral sources should expect a label from us. Yet, currently, "Physicians refer to consultants for diagnosis. They refer to PTs for treatment. Autonomy will be actualized when physicians refer to PTs to obtain diagnoses."" 

At the student physical therapist, we know we do not have all the answers, but at the very least we want to bring the question to the table. Are you practicing and documenting in a model of pathoanatomy or pathokinesiology? What movement system do you follow? Do you think physical therapists should adopt a specific movement pattern? 

Article: The Human Movement System: Our Professional Identity

-Jim       

References: Sahrmann, Shirley. "The Human Movement System: Our Professional Identity."Physical Therapy (2014): 3.1-29. Web. 15 June 2014.

A couple months ago, I subscribed to the premium portion of The Manual Therapist. Dr. E presents a very eclectic approach with various techniques with which I had not been familiar. One of the prime components of Dr. E's assessment and treatment techniques includes repeated loading. While this might be associated with the McKenzie school of thought, his reasoning has more of a neural approach. Since my neck hurt more on one side, I wanted to look for an asymmetry to treat. With cervical retraction and sidebend, both sides were painful, but I was especially limited to the R. Noting the asymmetry, I proceeded to perform repeated motions in the limited direction which resulted in increased range and decreased pain. Part of the theory is that by getting to the end-range repeatedly, we can re-teach the nervous system that it is okay to go in that direction and possibly others. A common saying for McKenzie type exercises is 10 repetitions 6-8 times a day. With Dr. E's approach, the more the motion is performed, the better. This applied to me. I noted the more I did the exercise, the longer I could go without pain and with increased motion. That evening I had my girlfriend do a cervical manipulation and thoracic manipulation which helped my pain, but within 30 minutes, I was back to the prior levels. The next 2 days, I did the cervical retractions and right sidebend 10x every 30 minutes throughout the day (give or take). Each time I did the exercises, I found I could go longer before the pain and stiffness returned. After 48 hours, I was 95% better.

There are two important components I took from this experience. First, repeated loading can be an incredibly useful assessment and treatment technique, when applied properly. With the majority of people being rapid responders, we should get almost immediate changes with pain and/or motion. Secondly, it is frustrating how long we often have to wait for patients to be evaluated due to length of time after referral, lack of awareness of what PT can offer, or other reasons. The sooner patients can access physical therapy, the sooner physical therapy can begin to help patients on the road to recovery.

-Chris

Check out Brian's new sports physical therapy and performance website: www.thesportsperformancept.com

If you are interested in the current functional/return to sport tests, residency/fellowship from current residents/directors, sports physical therapy taping techniques, performance drills & exercises, relevant sports literature, and clinical pearls for your athletes this is a great resource for you.  Most importantly, it is primarily video based!

*** Brian will continue to work on the student physical therapy website and started his new website during residency after he and his colleagues determined there was a need for video based education for sports physical therapy ***

The problem

In the general public there seems to be a lack of awareness regarding neural dynamics. Everyone knows muscles and joints require movement, but people do not think about the nervous system as a mobile unit. As a profession, physical therapy is gaining more knowledge regarding neural dynamics and incorporating these principles into our treatment sessions and home exercise programs. Unfortunately, we are not doing an adequate job explaining to patients WHY we are performing these exercises. 

What is important to know about the nervous system?

The body is one unit of interconnected nerves stemming from the brain. Healthy nerves require regular movement to stay lubricated and mobile. Unhealthy nerves are less pliable and can get trapped or compressed creating nerve tension. Decreased pliability increases the risk of injury because of the high amount of oxygen required by the nervous system. The nervous system receives 20% of the body’s blood supply, yet comprises only 2% of the body’s weight. It relies on adequate oxygen to function, and whenever that supply is disrupted, problems (manifested as tension) occur.

The above paragraph is brief summary of a 2009 3 part series, by Todd Hargrove on Nerve Mechanics. These easy to read blog posts will give you simple tips to explain nerve pain to your patients. 

-Jim