MEDICAL REHABILITATION OF LOCOMOTORY DISEASES

MEDICAL REHABILITATION OF LOCOMOTORY DISEASES

 

ANATOMY AND KINESIOLOGY OF THE MUSCULOSKELETAL SYSTEM

 

Skeletal Muscles

Bodily movement is carried out by the interaction of the muscular and skeletal systems.  For this reason, they are often grouped together as the musculo-skeletal system.  Muscle is attached to bone by tendons and other tissues, and exerts force by converting chemical energy into tension and contraction.  Skeletal muscles which cause movement of a joint are connected to two different bones and contract to pull them together. Our bodily needs demand that muscles accomplish different chores, so we are equipped with three types of muscles.

Cardiac muscle, found only in the heart, powers the action that pumps blood throughout the body.  Its big features are endurance and consistency.

Smooth muscle surrounds or is part of the internal organs.  Smooth muscle is found in the digestive system, blood vessels, bladder, airways and, in a female, the uterus.  It has the ability to stretch and maintain tension for long periods of time.  Both cardiac and smooth muscles are called involuntary muscles, because they cannot be consciously controlled.

Skeletal muscle carries out voluntary movements, and is what we use for movement in daily life and during exercise.  The human body has more than 650 muscles, the body’s most abundant tissue, comprising about 23% of a woman’s body weight and about 40% of a man’s body weight.  Skeletal muscles can do a short, single contraction (twitch) or a long, sustained contraction (tetanus), and might ache after strenuous exercise.       

The stomach is an organ of the alimentary canal, a muscular tube that forms part of the digestive system.  The wall of the stomach contains smooth muscle tissue.  Contractions of the smooth muscles of the alimentary canal serve to mix food with digestive juices, and to move the resulting mixture further along (peristalsis).  Smooth muscles are called involuntary muscles, because they cannot be consciously controlled.  As we have no control over the smooth muscle tissue of the stomach, we cannot consciously contract it, or exercise it.  Thus, there are no exercises to strengthen the stomach or using the stomach to move the spine.  The term “stomach” therefore does not belong into Pilates class.

 

Anatomy of Skeletal Muscle

According to the sliding filament model, myosin cross-bridges attach to a binding site on the actin filament and bend slightly, thus pulling on the actin filament.  The filaments slide past one another, thus shortening the sarcomeres, thus shortening the myofibrils, thus shortening the muscle fiber.  

Then the head of the myosin cross-bridge can release, straighten, combine with another binding site further down the actin filament, and pull again, thus shortening the sarcomere, (myofibril and muscle fiber) more.  The actions of the myosin molecules are not synchronized – at any given moment, some myosins are attaching to the actin filament, others are creating force (pulling) and others are releasing the actin filament).  This process can be repeated for as long as the muscle fiber is stimulated, or until the point of maximal shortening of the sarcomere. 

When the muscle fiber is no longer stimulated, the cross-bridges break down, and the muscle fiber relaxes.

 

Physiology of Skeletal Muscle

A muscle fiber contracts only when stimulated by its nerve, the motor neuron.  A nerve impulse from the motor neuron translates into a muscle impulse that affects the whole muscle fiber at once, for as long as the stimulation continues.  A stimulated skeletal muscle fiber responds to its fullest extend, i.e., it has an all-or-none response.  While each muscle fiber is connected to only one axon of a motor neuron, a motor neuron may have many densely branched axons, connecting to many muscle fibers, constituting a motor unit.  When a motor neuron transmits an impulse, all the muscle fibers it links to are stimulated to contract simultaneously, and also in an all-or-none response.

A whole muscle is composed of many motor units controlled by different motor neurons, which respond to different thresholds of stimulation.  If only the motor neurons with low thresholds are stimulated, few motor units contract, and the muscle contracts with minimal tension. At higher intensities of stimulation, additional motor neurons respond, and more motor units are activated, which produces a stronger muscle contraction.  Such an increase in the number of motor units being activated is called recruitment. As the intensity of stimulation increases, recruitment of motor units continues until, finally, all possible motor units in that muscle are activated and the muscle contracts with maximal tension.

A single stimulus of threshold strength activates some of a muscle’s motor units, which makes the muscle contract and then relax.  This action lasts only a fraction of a second and is called a twitch. The response time between stimulation and muscle reaction determines the classification into fast twitch or slow twitch fibers.  Fast-twitch fibers are capable of developing greater forces, contracting faster to produce bursts of power and have greater anaerobic capacity.  In contrast, slow-twitch fibers develop force slowly, can maintain contractions longer, have greater endurance and higher aerobic capacity.  The skeletal muscles of an average person contain about half fast twitch and half slow twitch muscle fibers.  Certain athletic activities promote increased percentage of fast twitch muscle fibers (Olympic sprinter), or slow twitch muscle fibers (Olympic marathoner).

A muscle fiber exposed to a series of stimuli of increasing frequency reaches a point when it is unable to completely relax before the next stimulus in the series arrives.  When this happens, the force of individual twitches combines, a process called summation.  When the resulting forceful, sustained contraction lacks even partial relaxation, it is called a tetanic contraction (tetanus).  Summation and recruitment together can produce a sustained contraction of increasing strength.  Although twitches may occasionally occur in skeletal muscles (e.g., eyelid twitch), such contractions are of limited use.  More commonly muscular contractions are sustained.   Even when a muscle appears to be at rest, a certain amount of sustained contraction is occurring in a small fraction of the total number of its fibers.  This muscle tone is important particularly in maintaining posture, and also enables the muscle to resist passive elongation or stretch.

When the muscle is stretched, so is the muscle spindle, which records the change in length (and how fast) and sends signals to the spine which convey this information.  This triggers the stretch reflex which attempts to resist the change in muscle length by causing the stretched muscle to contract.  The more sudden the change in muscle length, the stronger the muscle contractions will be (plyometric, or “jump”, training is based on this fact).  This basic function of the muscle spindle helps to maintain muscle tone and to protect the body from injury.  However, ballistic stretching may cause a muscle contraction so strong it tears the muscle fibers or tendons, causing injury.  One of the reasons for holding a stretch for a prolonged period of time (static stretching) is that as the muscle is held in a stretched position, the muscle spindle becomes accustomed to the new length and reduces its signaling.  Gradually, you can train your stretch receptors to allow greater lengthening of the muscles.

When muscles contract (possibly due to the stretch reflex), they produce tension at the point where the muscle is connected to the tendon, where the golgi tendon organ is located.  The Golgi tendon organ records the change in tension, and the rate of change of the tension, and sends signals to the spine to convey this information.  When this tension exceeds a certain threshold, it triggers the lengthening reaction which inhibits the muscles from contracting and causes them to relax.  This basic function of the golgi tendon organ helps to protect the muscles, tendons, and ligaments from injury.  The lengthening reaction is possible only because the signaling of golgi tendon organ to the spinal cord is powerful enough to overcome the signaling of the muscle spindles telling the muscle to contract.  Another reason for holding a stretch for a prolonged period of time is to allow this lengthening reaction to occur, thus helping the stretched muscles to relax.  It is easier and more beneficial to stretch, or lengthen, a muscle when it is not trying to contract.

 

Skeletal Muscle Action.

The contraction of a muscle does not necessarily mean that the muscle shortens; it only means that tension has been generated.  When muscles do cause a limb to move through the joint’s range of motion, they usually act in the following cooperating groups:

Agonists cause the movement to occur.  They create the normal range of movement in a joint by contracting.  Agonists are also referred to as prime movers since they are the muscles that are primarily responsible for generating the movement.

Antagonists act in opposition to the movement generated by the agonists and are responsible for returning a limb to its initial position.

Synergists assist the agonist and make its action more effective by helping to hold the joint steady and keeping the two bones around the joint aligned.  Synergists are also sometimes called stabilizers.

Primary opposing muscle groups: calves/tibialis anterior,  quadriceps/hamstrings,  hip flexors/gluteals,  erector spinae/abdominals,  pectorals/upper back,  latissimus dorsi/deltoids,  biceps/triceps.

Muscles can contract in the following ways:

Isometric contraction – This is a contraction in which no movement takes place, because the load on the muscle exceeds the tension generated by the contracting muscle.  This occurs when a muscle attempts to push or pull an immovable object.

Isotonic contraction – This is a contraction in which movement does take place, because the tension generated by the contracting muscle exceeds the load on the muscle.  This occurs when you use your muscles to successfully push or pull an object.  Isotonic contractions are further divided into two types:

Concentric contraction – This is a contraction in which the muscle decreases in length (shortens) against an opposing load, such as lifting a weight up.  During a concentric contraction, the muscles that are shortening serve as the agonists and hence do all of the work.

Eccentric contraction – This is a contraction in which the muscle increases in length (lengthens) as it resists a load, such as returning a weight to starting position, or resisting a stretch.  During an eccentric contraction the muscles that are lengthening serve as the agonists (and do all of the work).         

As a result of excessive use, muscles may hypertrophy, that is, increase in size because of an increase in size of the individual muscle cells.  As a result of prolonged disuse, muscles may atrophy, or diminish in size, and become weaker.

 

PRINCIPLES OF KINESIOLOGY

It is agonist, antagonist, and synergistic muscles operate to accomplish joint motion.

1. An agonist, or prime mover, is any muscle that can cause a specific joint motion. For ex­ample, the biceps brachii contracts to cause elbow flexion.

2. An antagonist is any muscle that can produce a motion opposite to the specific agonist motion. For example, triceps brachii is an antagonist to elbow flexion. Antagonists are normally completely relaxed during contraction of an agonist (except during a rapid ballistic motion).

3. Synergistic muscles normally contract to remove unwanted actions of agonists or to sta­bilize other (usually more proximal) joints. For example, during elbow flexion by the biceps brachii, the forearm pronators contract to remove the undesirable supination that the biceps would produce.

What forces normally produce motion at joints? Muscle contraction and gravity, with each serving as the prime mover for about 50% of all joint movements.

This is the three types of muscle contraction.

Isotonic (A) and isometric (B) contraction.

1. Shortening, concentric, or isotonic contraction occurs when the muscle’s force ex­ceeds the load. Hence, the muscle shortens to produce joint motion while maintaining constant tension.

2. Isometric or static contraction occurs when the muscle force equals the load. The muscle maintains the same length, and the joint does not move.

3. Lengthening or eccentric contraction occurs when muscle force is less than the load. This normally occurs when gravity is the prime mover. To control the effect of gravity, eccentric con­traction occurs in the muscle(s) that opposes the direction that gravity is tending to move the joint.

Two muscles together often perform the same function. How can you eliminate one of the muscles to evaluate the other muscle in relative isolation?

Three muscle elimination procedures are used commonly:

1. Placing a muscle at a mechanical disadvantage by positioning the part so that the muscle to be eliminated will have no substantial vector component in the direction of the func­tion to be tested.

2. Placing a muscle at a physiologic or length disadvantage by positioning the part so that the muscle is slackened or has much of its shortening capability used up by performing a func­tion other than the one being tested.

3. If the muscle to be eliminated has several functions, it can be reciprocally inhibited from participating in the tested function by forcibly performing a function antagonistic to one of its other functions.

How is muscle strength graded? Manual muscle strength assessment is accomplished by proceeding cephalad down in the order of innervation from the brachial plexus, through the lumbosacral plexus. If specific nerves are in question, examine muscles in the proximal-to-distal order in which they receive their motor branches. Resistance is best assessed using the “make and break” technique, in which the exam­iner overpowers a patient’s fixed mid-muscle-length contraction.

Principle positive work

In clinical practice, the following hierarchy of ordinal-ranked categories is used. For greater reproducibility, a continuous measure such as hand-held dynamometry is superior.

5 = Normal power against gravity and the usual amount of resistance

4 = Muscle contraction possible against gravity and less than the normal amount of resistance

3 = Muscle contraction possible only against gravity, not with resistance

2 = Joint movement possible only with gravity eliminated

1 = Flicker of contraction with no movement

0 = No contraction detectable

 

SPINE

This is the major ligaments of the spine.

Ligaments of the spine

Anterior longitudinal ligament. Posterior longitudinal ligament. Ligamenta flava. Interspinous and supraspinous ligaments.

 

 

What are the parts of the intervertebral disc? A peripheral, laminated, fibrocartilaginous anulus fibrosus and a central, gel-like nucleus pulposus. The anulus fibrosus contains the nucleus pulposus fluid between the adjacent vertebral bodies. The nucleus pulposus serves as a hydraulic load-dispersing mechanism, so that as the spine bends in any direction, the compressive loads borne by that side of the disc are redistributed over a larger surface area, thereby reducing the pressure.

 

Intervertebral disc

 

Why do most intervertebral disc protrusions occur posterolaterally?

1. The disc is reinforced anterolaterally by the anterior longitudinal ligament and postero-medially by the posterior longitudinal ligament. Posterolaterally, there are no extrinsic support­ing ligaments.

2. The nucleus pulposus is eccentrically located closer to the posterior aspect of the disc, causing the posterior anulus to have the smallest radial dimension and offer the least support.

3. The posterior anulus is thinnest in the superior-inferior dimension at cervical and lumbar levels, causing it to suffer the greatest strain.

4. Because flexion is the most predominant spine motion, the posterior anulus receives the most repetitive tensile stresses.

5. The posterolateral anulus is subject to the highest intralaminar shear stresses, causing in-tralaminar separation.

 

Describe the course of the spinal nerves in the spine. At most levels, dorsal and ventral roots joint to form spinal nerves as they enter the inter-vertebral foramen. The dorsal root ganglia are located on the spinal nerve at this point. As spinal nerves exit the intervertebral foramen, they terminate by dividing into dorsal and ventral rami. Cervical spinal nerves exit above the vertebra of the same number. The C8 spinal nerve emerges between the C7 and Tl vertebrae, which causes all thoracic, lumbar, and sacral nerves to exit below the vertebrae of the same number. Because lower spinal nerves must descend to their inter-vertebral foramina from their higher point of origin from the spinal cord, they typically occupy the upper portion of their intervertebral foramen.

Why do herniated lumbar intervertebral discs commonly miss the nerve that exits at that level and instead affect the next lower spinal nerve roots? Lumbar intervertebral foramina are large, and because the nerves occupy the upper part of the foramen and the disc is related to the lower part of the foramen, posterolateral disc hernia-lions commonly miss the nerve in the foramen. Instead, they tend to affect the roots of the next lower spinal nerve, which occupy the most lateral part of the spinal canal before exiting from the next lower intervertebral foramen. For example, a herniated L4-5 disc will typically miss the L4 nerve and affect the L5 roots.

Lumbar intervertebral disc

What are the uncovertebral or Luschka’s joints? The lower five cervical vertebrae contain uncinate processes that protrude cranially from the lateral margins of the superior surface of their bodies. Luschka’s joints begin to develop in the second decade of life as degenerative clefts in the lateral part of the intervertebral disc just medial to the uncinate processes. Degeneration begins at this point because it is where the cervical discs are narrowest in their superior-inferior dimension and hence subject to greatest tensile stresses during motion. Hypertrophic degenerative changes can involve Luschka’s joints or the posterior portion of the cervical disc, which is the next thinnest part of the disc. Hypertrophic bars developing in the posterior disc can encroach both nerve roots and spinal cord.

What are lateral recesses? What is their significance? Lateral recesses are a normal narrowing of the anteroposterior (AP) dimension of the lateral portion of the spinal canal at the L4, L5, and S1 levels. They occur because the pedicles become shorter in their AP dimension at these levels. This brings the superior articular processes and facet joints close to the posterior aspect of the lateral part of the vertebral bodies. The pedicle forms the lateral wall of the recess.

As the L4-S1 nerve roots descend the spinal canal, they each course through a lateral recess before exiting their intervertebral foramen. When hypertrophic degenerative changes in­volve the superior articular process, it can reduce the distance between this process and the vertebral body to < 3 mm, producing lateral stenosis with the potential for nerve root en­croachment. Hypertrophic changes involving the more medially situated inferior articular process will more likely produce a central stenosis of the spinal canal. Facet joints also form the posterior boundary of the intervertebral foramen, where hypertrophic changes can produce foramina stenosis.

What anatomic and mechanical features of the lumbosacral junction predispose L5 to spondylolysis and spondylolisthesis?

The steep inclined plane of the sacral angle (commonly 50° from horizontal) predisposes the L5 vertebra to slide forward on S1 under a gravitational load. This slippage is resisted by the im-paction of the inferior articular processes of L5 against the superior articular processes of the sacrum. These forces and their reactions concentrate substantial shearing stresses on the pars inter-articularis of the L5 lamina. Hence, spondylolysis is most commonly a stress fracture. Whether a spondylolisthesis develops depends on the ability of the intervertebral disc, anterior longitudinal ligament, and iliolumbar ligaments to resist anterior displacement of the L5 vertebral body.

Are the deep back muscles contracted or relaxed in the upright position? In the upright position, the spine is in relatively good equilibrium because the line of gravity falls through the points of inflection of each of the curves of the spine. As a result, activity in the major deep back muscles (erector spinae, semispinalis, multifidus, and rotators) is negligible, and the ligaments of the spine resist any applied moments.

Which muscles are responsible for producing the major spine motions?

Flexion—The anterior abdominal muscles initiate flexion, but as soon as the spine is out of equilibrium, gravity becomes the prime mover under the control of an eccentric contraction of the deep back muscles. A concentric contraction of the deep back muscles returns the spine to an upright position.

Extension—Spinal extension is initiated by the deep back muscles, with gravity becoming the prime mover as soon as the spine is out of equilibrium. The anterior abdominal muscles control gravity with an eccentric contraction and return the spine to an upright position with a concentric contraction.

Lateral bending—Lateral bending is initiated by the ipsilateral deep back, abdominal, psoas major, and quadratus lumborum muscles. Once started, gravity becomes the prime mover under the control of eccentric contraction of the same muscles on the contralateral side, which also contract concentrically to return the spine to the upright position.

Rotation—Rotation of the front of the trunk to one side is produced by the ipsilateral erec­tor spinae and internal abdominal oblique muscles and the contralateral deeper back muscles and external abdominal oblique. Rotation of the face to one side is also produced by the ipsilat­eral splenius, contralateral sternocleidomastoid, and other cervical rotators.

What do dorsal rami of spinal nerves innervate? Dorsal rami innervate the skin of the medial two-thirds of the back from the interauricular line to the coccyx (top of the head to the tip of the tail), deep muscles of the back, posterior liga­ments of the spine, and the facet joint capsules.

 

UPPER LIMB

What structure provides the strongest support for the acromioclavicular joint? The coracoclavicular ligament, which descends from the distal clavicle to the coracoid process. This ligament must be torn to produce the major stepdown of the acromion below the clavicle in grade 3 acromioclavicular joint injuries.

Bone anatomy

What structural features cause the shoulder (glenohumeral) joint to be a highly mobile but relatively unstable joint? The relatively poor bony congruence between the glenoid and humeral head and a slack capsule.

What dynamic features help maintain shoulder joint contact through the full range of abduction? The rotator cuff muscles stabilize the shoulder by varying their medially directed vector forces. In early abduction, the deltoid tends to sublux the humeral head superiorly. This is offset by increased tension in the superior capsule by the simultaneous contraction of the supraspinatus and by the slightly downward vector pull of the subscapularis, infraspinatus, and teres minor muscles. In the middle range of abduction, the subscapularis turns off to allow the infra­spinatus and teres major to externally rotate the humerus and bring the greater tubercle posteri­orly under the acromion (which is the highest part of the coracoacromial arch). This prevents its impingement against the arch.

Muscle anatomy

How does medial and lateral winging of the scapula occur? The medial border of the scapula is normally kept closely applied to the thoracic wall by the resultant vector forces of its medially and laterally tethering muscles, the trapezius and serratus anterior. If the serratus anterior is paralyzed, the medial border will wing away from the chest wall and be displaced medially by the unopposed retraction of the trapezius (medial winging). If the trapezius is paralyzed, the medial border will also wing but will be displaced laterally by the unopposed protraction of the serratus anterior (lateral winging).

What are the two major “crutch-walking” muscles of the shoulder? The upward vector force of the crutches at the shoulder is primarily offset by the downward pull of the pectoralis major and latissimus dorsi muscles acting on the humerus.

Why is the elbow a relatively stable joint? The trochlear notch of the ulna has a good grip on the humeral trochlea, and there are strong, relatively taut radial and ulnar collateral ligaments.

Where is the axis for pronation and supination of the forearm located? Proximally, it passes through the center of the radial head; distally, it passes through the ulnar head. Hence, during pronation and supination, the radius scribes half a cone in space about the ulna.

How are major loads transferred from the radius at the wrist to the ulna at the elbow? They are transferred across the interosseous membrane, whose fibers run primarily from the ulna upward to the radius. Hence, loads ascending the radius will tense this membrane and be transferred to the ulna.

 

WRIST AND HAND

Which carpal bones are most frequently injured? The major weight-bearing carpal bones are most frequently injured: the scaphoid by a neck fracture and the lunate with a palmar dislocation. In one-third of scaphoid fractures, there is nonunion, because about one-third of scaphoids receive a blood supply only to their distal end. The lunate tends to dislocate palmarly during hyperextension injuries, because it is wedge-shaped with the apex of the wedge pointing dorsally.

 

Why doesn’t carpal tunnel syndrome cause sensory abnormalities over the palm? The palmar cutaneous branch of the mediaerve passes superficial to the flexor retinaculum.

How can the flexor digitorum profundus be eliminated in order to test the flexor digitorum superficialis tendons in isolation? To test the ability of the flexor digitorum superficialis to flex the proximal interphalangeal (PIP) joint of a finger, hold the rest of the fingers into forcible hyperextension by resistance over the distal phalanges. This is effective because the individual tendons of the profundus generally arise from a common tendon that attaches to its muscle mass, whereas each of the tendons of the superficialis has its own separate muscle belly. Hence, placing the other fingers into extension puts all of the profundus under stretch and eliminates it as a PIP joint flexor.

How can the extensor digitorum be eliminated to isolate and test the extensor indicis as the last muscle innervated by the radial nerve? The extensor indicis is tested by metacarpophalangeal (MP) joint extension of the index finger with the other fingers held in flexion at their MP joints. This is effective because the ten­dons of the extensor digitorum are cross-linked over the dorsum of the hand by intertendinous connections. Therefore, if the rest of the tendons are pulled distally over their MP joints by forcible flexion, it tethers the tendon to the index finger distally and makes the extensor digito­rum ineffective as an index finger MP joint extensor.

Why are the motions of the thumb at right angles to the similar motions of the fingers? In the resting hand, the thumb is internally rotated 90° relative to the fingers. Hence, flexion and extension of the thumb occur in a plane parallel to the plane of the palm, and abduction and adduction of the thumb occur at right angles to the plane of the palm, with the thumb moving away from the palm in abduction and toward the palm in adduction. Opposition involves almost 90° of further internal rotation of the thumb at its carpometacarpal joint.

What is the normal digital balance mechanism of the fingers? At the MP joint, there is one extensor, the extensor digitorum (though there is an addi­tional extensor of the index and little fingers), balanced against four flexors: the interossei, lumbrical, and flexor digitorum profundus and superficialis. At the PIP joint, there are three extensors (interossei and the lumbrical and extensor digitorum) balanced against two flexors (flexor digitorum profundus and superficialis). At the distal interphalangeal (DIP) joint, there are three extensors—interossei and the lumbrical and extensor digitorum—balanced against one flexor, flexor digitorum profundus. The muscles contributing to the extensor balance form an extensor hood mechanism, which splits into lateral and central bands over the PIP joint, with the central band inserting into the base of the middle phalanx and the lateral bands insert­ing into the base of the distal phalanx. Over the PIP joint, all three bands are connected by the triangular membrane, which holds the lateral bands in their normal dorsal position. An oblique retinacular ligament of Landsmeer splits off the lateral bands to tether them ventrally to the proximal phalanx.

 

LOWER LIMB

What structural features make the hip a relatively stable joint?

1. Good congruence between the femoral head and the deeply concave acetabulum, which with its labrum forms more than half a sphere.

2. Strong capsular ligaments, two of which—the iliofemoral and ischiofemoral ligaments— are maximally taut in the extended upright position (the usual weight-bearing position).

Bone anatomy

What are the unique features of the hip joint capsule and its blood supply? What is their clinical significance? The anterior hip joint capsule attaches to the intertrochanteric line of the femur, thereby completely enclosing the anterior femoral neck. The posterior capsule encloses the proximal two-thirds of the femoral neck. Therefore, the femoral head and most of the femoral neck are intracapsular. This has two clinically important effects. First, it requires that most of the blood supply to the femoral head (mostly from the medial femoral circumflex artery) must ascend the femoral neck. Hence, except for the small branch of the obturator artery that enters the head with the ligament of the femoral head (ligamentum teres), most of the blood supply to the femoral head is compromised by femoral neck fractures. Second, because the capsule attaches to the femoral neck so low, the upper femoral metaphysis is intracapsular. Because the metaph-ysis is the most vascular part of a long bone, hematogenously spread infection to the upper femoral metaphysis can easily produce a septic arthritis. In most other joints, the metaphyses are extracapsular.

Even though the long, obliquely situated femoral neck predisposes the hip to high shearing forces and fracture, are there any physiologic advantages to this unique design? The long, obliquely situated femoral neck has the salutary effect of displacing the greater trochanter farther from the abduction-adduction axis of the femoral head, thereby lengthening the moment arm of the gluteus medius and minimus muscles. In standing on one leg, the gravita­tional vector acting on the adduction side of the hip joint is on a moment arm approximately three times as long as the gluteus medius and minimus moment arm. Therefore, these muscles have to produce a force approximately three times as great as the gravitational vector to offset the hip adduction tendency. If the femoral neck were any shorter or more vertically oriented, as in a valgus hip, the gluteus medius and minimus moment arm would be shortened, requiring these muscles to apply more force to offset the gravitational vector. The long moment arm of the normal femoral neck thereby reduces the loads across the hip and helps protect the hip from de­generative arthritis.

What is the best way to test the right gluteus medius and minimus muscles? Ask the patient to stand on the right leg. If these muscles are weak or paralyzed, the left side of the pelvis will sag under the influence of the gravitational adduction vector (Trendelenburg sign).

At what point in the gait cycle is the gluteus maximus most active? Why? At heel strike of the ipsilateral limb. This offsets the effect of the ground reaction vector, which acts anterior to the hip at this point and therefore tends to cause the trunk to flex on the thigh.

When is the iliopsoas most active during the gait cycle? Why? At toe-off, the iliopsoas acts as a hip flexor to offset the ground reaction vector, which is then acting posterior to the hip to cause hip extension.

Why is the knee joint most stable in extension?

1. Because the anterior portion of the femoral condyle is less curved than the posterior condyle, the congruence and area of contact between the femoral and tibial condyles are great­est in extension. Hence, the pressures acting across the knee are lowest in extension.

2. The tibial and fibular collateral ligaments are maximally taut in extension.

3. The anterior cruciate ligament is completely tense only in extension.

Why are the gastrocnemius and soleus muscles the most active lower limb muscles in standing? In quiet standing, the line of gravity falls slightly behind the hip joint, slightly anterior to the knee, and 2 inches anterior to the ankle joint axis. At the hip, the tendency of the line of gravity to hyperextend the hip is resisted by the tension in the iliofemoral (and ischiofemoral) ligaments. Therefore, hip flexor muscle activity is generally unnecessary. The line of gravity tends to hyperextend the knee, and tension in the posterior capsule probably helps resist this. However, the activity in the gastrocnemius muscle, which is primarily to stabilize the ankle, also helps prevent back-knee. At the ankle, the long moment arm of the line of gravity makes it a strong ankle dorsiflexor. The activity in the gastrocnemius and soleus muscles resists this ankle dorsiflexion tendency.

 

FOOT AND ANKLE

What is the most osteologically stable position of the ankle? Why? Dorsiflexion. Both the talar trochlea and tibiofibular mortise have wedge-shaped articular surfaces that are wide anteriorly and narrow posteriorly. In dorsiflexion, the wide anterior part of the talar trochlea is wedged back into the narrow posterior part of the tibiofibular mortise.

At what joint does most of the pronation and supination of the foot occur? The subtalar joint permits most of the pronation (eversion) and supination (inversion) of the foot, but the transverse tarsal and tarsometatarsal joints also contribute.

When are the ankle dorsiflexor muscles active during gait? The ankle dorsiflexors are active isometrically during swing to prevent gravity from causing foot-drop and eccentrically from heel strike to flat foot (the loading response) to control the plan­tar flexion vector exerted on the calcaneus by the ground reaction.

Which nerve of the foot is homologous to the mediaerve in the hand? The medial plantar nerve. It generally supplies the plantar skin of the medial two-thirds of the foot and medial three and one-half digits, the intrinsic muscles of the great toe except for the adductor hallucis, the first lumbrical, and the flexor digitorum brevis (homologous to the flexor digitorum superficialis of the upper limb). The lateral plantar nerve is also homologous to the ulnar nerve.

 

MUSCULOSCELETON REHABILITATION

 

NECK PAIN

What functional anatomy of the cervical spine must be understood to evaluate pain in the neck and from the neck? The cervical spine is composed of two segments. The upper consists of the occiput, atlas (Cl), and axis (C2). The lower comprises functional units C3-C7. The movement of the occiput and Cl causes flexion-extension, the movement of Cl on C2 is rotation, and the movement of C3-C7 causes all ranges of motion.

Describe a functional unit. A functional unit is two adjacent vertebrae separated by an intervertebral disc and posteri­orly two laminae, two pedicles, and zygapophyseal joints termed facets.

A “pain in the neck” is a common complaint. Where in the cervical spine does pain originate? The tissue sites where nociception occurs are the posterior longitudinal ligaments, nerve roots and their dural sheaths, the facet capsules, and the neck muscles. Nociception occurs from mjury, irritation, inflammation, or infection of these sites. The intervertebral disc consists of annular fibers within a mucopolysaccharide matrix with no blood supply and no nerve endings other than minimal unmyelinated nerve endings in the outer peripheral annulus fibrosus. Consequently, only damage to the outer annular fibers can con­ceivably cause pain.

In evaluating pain from the cervical spine, what are the most important factors to con­sider? The nerve roots emerge from the cervical spine through the foramina, which contain the dorsal root ganglion and their dural sheath, both sites of nociception. Flexion opens the foramina, and extension closes them. Rotation and lateral flexion of the neck close the foramina on the con­cave side and open those on the convex side. Passive and active movement of the neck trigger pain by nerve compression.

In a clinical evaluation from history, what are the major factors to be determined? Every chief complaint can be elucidated using the mnemonic PQRST:

P      Palliative—determine the precise position or alleviating and exacerbating factors

Q      Quality of symptoms

R     Radiation of symptoms

S      Severity as experienced throughout the day and with various activities

T      Temporal factors—onset, duration, time the pain is worse, a movement(s) that cause or aggravate the pain

What is the Spurling test? The test defined by Spurling is reproduction of radicular pain by extending the neck, rotating it to one side, and pressing down on the head toward the side of complaint. A positive test repro­duces the radicular pain. The site of referred pain indicates which nerve root has been com­pressed: arm/forearm, C5; thumb, C6; middle finger, C7; fifth finger, C8.

Is it radicular pain or radiculous pain? Radicular pain indicates that a radicle (nerve root) has been compressed and referred to a dermatomal area. Radiculous pain is pain complained of without anatomic basis, pathophysio-logic pattern, or consistent findings. For example, a C5-6 intervertebral disk protrusion will en­croach on the C6 spinal nerve emerging through the C5-6 intervertebral foramen (see Figure).

Are x-ray studies of the cervical spine of precise diagnostic value? No. X-rays often show “pathology” that is irrelevant to the complaints. X-rays are only of value if they confirm the presence and indicate the site of pathology that can explain the symp­toms and physical signs.

What are the most common causes of neck pain or pain from the neck? Trauma. The trauma can result from an accident (often vehicular), postural position (e.g., poor ergonomics such as prolonged computer working), or emotional tension.

Is posture an important factor in causing neck pain? Yes. An exaggerated dorsal kyphosis (round back) places the head ahead of the center of gravity increasing the cervical lordosis. The weight of the head in this position is borne by the zy-gapophyseal joints (facets) and causes pain.

Has one tissue site of the cervical spine been considered the prevalent site of neck pain? The zygapophyseal joints (facets) have been so designated because injection of an irritating substance in them reproduces the pain and injecting an analgesic relieves the pain.

What is a whiplash injury? In a rear-end motor vehicle accident, the impact acutely forces the entire body forward, but the head does not move at the same time and undergoes translation forces with initial extension then reflex flexion. Normal flexion-extension does not occur, but translatory forces cause disc annular fiber damage and facet capsule excessive stress.

What is a stinger? This acute cervical injury in athletes may result in a transient paresis (paraplegia/quadriplegia).

Degenerative disc disease of the cervical spine is considered a cause of neck pain and arm pain from the neck. Is this a valid assumption and what are the causative factors? Degenerative disc disease occurs from age 30 on as a result of the aging process but is aggra­vated and accentuated by trauma. As the disc dehydrates with age, it narrows allowing the longi­tudinal ligaments to be separated from the vertebral bodies. The blood that seeps in between the ligament and the body gradually ossifies and forms osteophytes (spurs). These spurs narrow the foramen and can entrap the nerve roots.

Can headaches be caused by injury to the cervical spine? A condition termed cervicogenic headache occurs after an injury and responds favorably to neck therapy. Its pathoanatomic basis is not clear.

What is a “computer headache”? Although not yet an official disorder, computer headache occurs in people who spend much time at the computer especially if they wear bifocal glasses. The dorsal kyphotic posture with head forward and up increaes the cervical lordosis. That and emotional tension from intensity cause neck and head pain.

 What is thoracic outlet syndrome? The thoracic outlet is the space between the first rib, the clavicle, and the two scalene mus­cles. The nerves of the brachial plexus and the subclavian blood vessels pass through this space. Acute contraction or chronic contraction of the scalene muscles can compress the nerves and blood vessels causing paresthesia of the arm and hand. Diagnosis is made by the Adson sign— diminished radial pulse produced by having the patient take a deep breath with her head turned all the way to the side.

Thoracic outlet syndrome

What causes the headache from greater superior occipital neuralgia? The greater superior occipital nerve contains roots from Cl and C2 and a branch from C3. It emerges through the extensor capitis muscles and supplies the dermatomes of C1, C2, and C3 of the posterior occiput. When entrapped or traumatized, it causes a vertex occipital headache. An injection of an anesthetic agent around the nerve at the occiput confirms the diagnosis and re­lieves the headache.

Is cervical traction a viable therapeutic modality? Properly applied cervical traction has great value in cervical problems. It must comfortably pull the head upward and forward at a 30° angle and be applied twice daily and for periods of 30 minutes.

 

 

LOW BACK PAIN

Is low back pain (LBP) a common problem? Yes. Epidemiologic studies show that by the age of 20, 50% of the population has experi­enced LBP. By age 60 years, the incidence may be as high as 80%. LBP is second only to the common cold when it comes to symptoms prompting a physician visit.

What are the most common diagnoses of back pain?

In a number of studies, the most common diagnoses are actually nondiagnoses, such as “nonspecific LBP” or “degenerative disease.” More specific diagnoses include compression frac­ture, spondylolisthesis, malignancy, ankylosing spondylitis, and infection. Approximately 2% are diagnosed with “radiculopathy” or “sciatica.”

Does back pain have a natural history? Yes. LBP is usually self-limited. Because the incidence is over 50% and point prevalence in the 10-20% range, it is obvious that most individuals are able to deal with their pain for the period of time until resolution. However, in certain populations, the pain, complaints, and subse­quent disability become significant and difficult to resolve. Recurrence over time, which is not predictable, is also part of the natural history

Is there a way to prevent recurrences? There are ways to try to prevent recurrence, but few have proven effective. It makes sense to learn proper back care, exercises including back, abdominal, and back stabilizer strengthening, and stretches for the back and hamstrings. Patients can be educated to respond to acute episodes with nonsteroidal anti-inflammatory drugs (NSAIDs), ice or heat, and activity maintenance and to expect resolution in 3-7 days.

Are there really no abnormalities in people with so-called nonspecific LBP? There are many abnormalities in the spine of people with LBP. However, there is no conclu­sive evidence that these abnormalities are responsible for the patient’s complaints. Clinical stud­ies have shown a poor correlation between spinal x-ray abnormalities and LBP. Nonetheless, past generations of medical practitioners have told patients that their LBP was due to “arthritis” of the spine. More recently, as computed tomography (CT) scanning and magnetic resonance imaging (MRI) evolved and more abnormalities became visible, surgery has been recommended to remove architecturally observable but nonoffending discs. Even today, degenerative discs are blamed for LBP. BAK fusion, IDET (heat dissolution of discs), and a variety of other procedures are being performed to fix the problem.

A number of structures can potentially cause LBP. Anatomic studies have determined which structures have free nerve endings that transmit pain sensations, and irritating material has been injected into structures to determine if and where pain is caused. Newer techniques claim to dis­tinguish some of these structures by differential injection, specifically into the facet joint, the sacroiliac joint, or disc (discogram). These remain controversial and are generally only effective in a reliable patient without psychological, legal, or monetary reinforcers.

What is the most important tool to assess patients with LBP? Believe it or not, the history and physical examination remain the mainstays for evaluating LBP, despite the new expensive technology.

What factors of the history are most important?

The history is vital and may be more important than physical examination. Determine the onset and duration of the problem; the reason it occurred; its relation to work, automobile, or other injury; if litigation is involved; and if there is financial remuneration. Define the pain care­fully: its location, relationship to position and activity, and time of day it is most prominent. Determine if there are associated symptoms such as pain in an extremity, numbness, or tingling. “Red flags” that may indicate serious pathology include bowel or bladder dysfunction, history of cancer, and generalized disorder such as end stage renal disease, osteoporosis, Paget’s disease, AIDS, or drug use. These red flags warrant further testing such as laboratory tests or imaging studies. In acute back pain without red flags, treatment usually only requires a history and physi­cal examination.

 

Low Back Pain «Red Flags»

 

Which structures should be examined in a patient with LBP and how is the examina­tion performed? The physical examination requires demonstration and lots of practice. Keep in mind that few physical exam techniques have been proven to identify the specific structure or disorder that is the cause of pain. The examination should address the low back, pelvis, hips, lower limbs, and gait and should include a neurologic examination for nerve root involvement. Examination points include back motion to look for asymmetric movement, re-creation of pain, and areas of mechan­ically limited motion or guarded motion (so-called spasm). Examine for tenderness, especially percussion tenderness over bony areas in the back and pelvis; the gait and balance including heel-and toe-walking and squat and return to upright; range of motion (ROM) of the lower extremi­ties; and any muscle tightness, especially the hamstrings and quadriceps. Pay particular attention to hip ROM, which is best examined in the prone position. LBP and hip pain with limited hip range may indicate osteoarthritis or other hip abnormality. A full peripheral neurologic examina­tion should be performed, including testing of reflexes, strength, and sensation.

Even though laboratory and imaging studies are not always accurate for diagnosing low back problems, should any tests be performed?

Imaging studies can be used to exclude severe disease. They are indicated only if red flags are present or if there is no improvement after several weeks of treatment. The initial study may be a plain x-ray. Other tests include bone scan, cross-sectional imaging (e.g., CT and MRI), and special tests, such as single photon emission CT (SPECT) scanning and discography. Remember that “abnormal” findings are expected on cross-sectional imaging. If leg pain is present, EMG, which is more specific than imaging, can be performed.

Is disability from LBP common? Patients with disability from LBP present a very different picture from those with acute, acute recurrent, or even chronic LBP who are still functioning. Despite improvements in diag­nostic and treatment techniques, disability from LBP has risen astronomically in the last couple of decades (as much as 2500%). We must look beyond pure physical explanation for this rise. Patients with diability from LBP that occurred either spontaenously or, more commonly, from an injury must also be assessed from a psychoemotional, social, and vocational viewpoint.

What are signs to look for in identifying the “disability syndrome”? The most common associations that indicate disability from an injury are not physical ones. The best predictors are history of prior injury with time off work, high Minnesota Multiphasic Personality Inventory (MMPI) scale 3 (hysteria), and high work dissatisfication scales. History and physical examination features that may help identify this syndrome include past episodes of back pain that led to disability, a long history of tests and surgical procedures, and a very detailed description of the event that generated their problem. Usually the patient reports that someone or something is at fault (e.g., oil on the floor, extra work that the patient was not supposed to do). Pain is often rated as very severe, such as 9 or 10 on a 0-10 scale, with 10 being excruciating pain. The patient may indicate a 10-level pain while sitting comfortably io apparent distress. Patients may be very demonstrative, grimace, position their bodies in unusual ways, complain of pain with minor movements, and have bizarre gait patterns. Check for Waddell’s signs, which indicate that organic abnormality is not the primary factor in the patient’s disability. These signs do not prove malingering but merely show that factors other than physical issues are significant contributors.

Signs (Waddell and Others) that LBP Is Not Organic

• Simulated axial loading—pressure on the neck leading to LBP

• Simulated rotation—neck extension or rotation with back motion leading to LBP

• General overreaction to physical examination

• Superficial tenderness

• Regional weakness (not following anatomic patterns)

• Widespread nonanatomic distribution of pain

• Regional sensory deficient (not following anatomic patterns)

• Distracted straight-leg raising (e.g., sitting position vs. supine)

How do you treat the patient with acute LBP? The offending structure is not known, and the natural history is to improve regardless of (or despite) treatment. Few treatments have proven to be beneficial, but several things may hasten the healing process. Reassurance can be very beneficial. Advise the patient that the process is “benign,” will not lead to long-term impairment, and most likely will not need major interven­tion. NSAIDs can give the double benefit of pain relief and decreased inflammation. Educate the patient on proper back care and exercises. Other treatments for acute LBP are usually not neces­sary. Several studies suggest that manipulation during the first 3 weeks decreases painful episodes, but this is controversial. Mild exercise may be helpful.

Is bed rest helpful? Bed rest was the mainstay of treatment at one time. However, a number of studies show that patients are better off doing as many normal activities as possible. This seems to shorten the course of disability and allow an earlier return to work. Thus, it is recommended that patients be up and about as much as tolerable and avoid anything that significantly increases pain.

What if the pain persists for several weeks after the initial treatment? If pain persists, it is reasonable to do some minor investigations, starting with lumbosacral spine x-ray. Additional treatment depends on the severity of discomfort and degree to which it in­terferes with function. More tests and treatment can be performed, but the risk-benefit and cost-benefit ratios should be considered. If the pain remains severe, a regular therapy program can be instituted. Other treatments include trigger point injections with lidocaine (xylocaine) or lidocaine with steroids; injections are easy to perform.

If pain does not resolve in several months and the individual is not disabled but is distressed. repeat reassurances because patients may fear severe illness. If not already performed, imaging studies are appropriate. Bone scan and MRI should be interpreted cautiously and correlated clini­cally. Determine the severity of pain perception and how it interferes physically, psychcosocially, and psychoemotionally with function. Treatment options include medications such as NSAIDs. tricyclic antidepressants, and acetaminophen; injections including sacroiliac joint, facet joint, and local myofascial trigger points; and alternative medicine techniques such as acupuncture.

What about the patient who is disabled by the pain? Other factors contributing to the pain must be identified. There has been a large movement toward treating “benign” or “nonmalignant” pain problems with opioid medications and various injections, disc dissolution techniques, device insertion (spinal stimulation, morphine pumps), and surgery. However, they are unlikely to treat the entire problem. When etiology is not clearly defined and there are multiple inorganic signs, treat the functional loss and disability. This type of patient is best served by an interdisciplinary team approach (not multidisciplinary) such as a functional restoration program.

Who should treat patients with LBP? A variety of clinicians can initiate treatment, and it is appropriate for a primary care physi­cian to start the process. Unfortunately, by the time patients see a specialist, they may have un­dergone an MRI and been told the pain is due to disc problems or other misinformation. It is difficult to “unteach” the patient, especially because the general population places such credence on MRI findings. Physiatrists (physical medicine and rehabilitation physicians) are the best next line of treatment. Ideally, a physiatrist would be the best primary physician as well.

Should neurosurgeons or orthopedic surgeons be consulted first? Definitely not! If an internist has a patient with a gastrointestinal or cardiac problem that he cannot solve, does he send the patient to a GI surgeon or thoracic surgeon? No! The patient is re­ferred to a gastroenterologist or cardiologist. After an expert evaluation and treatment, these spe­cialists can make any appropriate surgical referrals. The same should occur with LBP, especially because internists receive less training in rehabilitation than in internal medicine subspecialities. In addition, a surgeon’s primary training is in surgery. They will not have the knowledge of the total armamentarium that physiatrists have at their disposal.

What is the bottom line for LBP?

• LBP is ubiquitous in the human race and not a disease.

• Degenerative disc disease and some of the anatomic sequelae of facet arthropathy or spurring are usual consequences of aging.

• The natural history of LBP is to improve with or without treatment, but certain treatments can hasten the process and are worthwhile.

• There is little or no correlation between anatomic abnormalities seen on imaging studies and the patient’s clinical symptoms or signs.

• It is the physiatrist’s job to discover serious problems presenting as LBP by identifying the red flags outlined in the AHCPR guidelines. This guideline is worth requesting (remember that the guideline only applies to acute LBP).

• Treatment comprises reassurance, NSAIDs, and having the patient stay out of bed and be active.

• Disability from LBP is a different disorder than acute LBP, and a host of factors contribute to it. It must be evaluated and treated differently than acute LBP.

• Special injection techniques are sometimes indicated in patients with LBP.

THE SHOULDER: ANATOMY, PATHOLOGY, AND DIAGNOSIS

Name all the joints involved in the shoulder girdle complex.

Glenohumeral joint                       Sternoclavicular joint

Suprahumeral joint                         Sternocostal joint

Acromioclavicular joint                  Costovertebral joint

Scapulocostal joint

These numerous joints indicate why the term shoulder girdle complex is better than shoulder joint.

Which tissues within the complex can be the site of nociception? Although many structures in the shoulder can have pain, the main ones are the tendon, the biceps tendon, the subdeltoid bursa, and the glenohumeral capsule. Nonshoulder structures that may cause pain include radicular pain from the cervical spine, cardiac ischemic pain, diaphragm irritation, lung inflammation, and various upper abdominal pathologies.

What muscles comprise the rotator cuff? One way of remembering them is by using the mnemonic SITS (supraspinatus, infraspinatus, teres minor and subscapularis). At rest, their function is glenohumeral stabilization. All contract isometrically in the dependent arm to prevent subluxation. Dynamically, all contract to abduct and forward flex the arm. All except the subscapularis contract in external rotation of the arm (see figure on following page).

Is there a difference between subdeltoid bursitis and supraspinatus tendinitis? The synovial linings of both the subdeltoid bursa and the glenohumeral capsule are contigu­ous with the supraspinatus tendon. Inflammation of the sheath inflames both.

Is it possible to differentiate a rotator cuff tendon partial tear from tendinitis by clini­cal means? No. A partial tear of the rotator cuff tendinopathy (RTC) causes segmental swelling that be­comes entrapped under the coracoacromial ligament similar to tendinitis.

Contents of the glenohumeral joint.

Is there a clinical test that confirms the diagnosis of a torn rotator cuff? No test on physical examination confirms the diagnosis of a complete tear, but clinically a complete tear is indicated by inability to abduct the arm from dependency, inability to externally rotate the arm, and the patient has a positive drop arm test. Magnetic resonance imaging (MRI) studies are useful in confirming tears and the extent of tendon damage.

What is the mechanism of the “drop arm test”? The arm cannot abduct but once abducted to horizontal can be briefly held there by the del­toid muscle. Because the supraspinatus muscle is not seating the humeral head into the glenoid fossa, the arm gradually or with minimal weight “drops.”

Aside from faulty shoulder abduction, is there another test to determine the presence of a complete rotator cuff tear? Yes. Because a portion of the rotator cuff is represented by the tendinous insertion into the tuberosity of the supraspinatus and infraspinatus muscles, in a complete tear, active external rota­tion of the arm is not possible.

Besides rotator cuff disease, what other differential diagnostic possibilities must be considered in evaluating shoulder pain?

Suprascapular nerve entrapment                        Thoracic outlet syndrome

Shoulder instability                                                   Cervical radiculitis

Acromioclavicular degenerative joint disease          Bicipital tendinitis

Is posture a factor in evaluating shoulder pain? Yes. An exaggerated dorsal kyphosis causes the scapula to rotate downward. This changes the alignment of the glenoid fossa and the proximity of the acromium, making impingement more possible.

Suggest a convenient way of initiating active-passive shoulder movement. Pendulum (Codman’s) exercises are a simple way of instituting active-passive motion of the glenohumeral joint. This is best achieved with the patient bent forward, with the arm in the depen­dent (pendular) position and the body “actively” moving to “passively” move the pendular arm.

What is a “frozen shoulder”? A frozen shoulder is capsular limitation that prevents full range of motion of the gleno­humeral joint. It is essentially adhesive capsulitis and adhesive bursitis in which the synovial tis­sues become adherent.

Name the three most common anatomic structures of the shoulder involved in shoulder impingement syndrome.

1. Subacromial bursa

2. Supraspinatus

3. Biceps tendon

What are the components of the scapulohunieral rhythm? This term indicates the movement of the humerus within the glenoid fossa and the scapula upon the rib cage when the arm abducts or forward flexes. At rest they are vertical, but as the humerus abducts (flexes), the scapula initially remains static then rotates to permit overhead ele­vation. The “rhythm” implies that for every degree of scapular rotation there are 2° of gleno-humeral movement. The ratio 2:1 is not totally accurate for the entire 180°.

Glenohumeral joint

How is complex regional pain syndrome (CRPS) managed? Prevention by early intervention is the best treatment. Intervention includes early active range of motion exercises and anti-inflammatory medications. Meaningful explanation to the pa­tient allays fear of aggravation and recurrence with movement. Steroids and stellate ganglion blocks have value as well.

What is the mechanism, diagnosis, and management of shoulder subluxation? Subluxation is partial dislocation. Subluxation can result from direct trauma but also occurs after acute stroke. The head of the humerus is held within the glenoid fossa by the glenohumeral capsule and the rotator cuff muscles. The supraspinatus muscle is predominant in support. In acute stroke, the supraspinatus muscle becomes flail and allows the head of the humerus to sublux. Management entails positioning the patient to avoid downward traction on the gleno­humeral joint from gravity. Glenohumeral positioning can be maintained by contraction of the supraspinatus muscle mechanically or electrically.

Is bicipital tendinitis an entity? The biceps tendon acts passively (mechanically) upon the humerus during abduction and forward flexion as the bicipital fossa passes over the tendon. Inappropriate glenohumeral friction that occurs over the tendon, which is contiguous to the subdeltoid bursa and glenohumeral cap­sule, results in tendinitis.

Bicipital tendinitis an entity

What structures other than the glenohumeral joint can cause pain in the shoulder region? Because of the number of joints in the shoulder girdle complex (a better term than “shoulder joint”), any or all can cause shoulder pain. These include the acromioclavicular joint and the ster-noclavicular joint. Pain can be referred to the shoulder region from the neck, chest, or abdomen as well. This indicates the need for a careful history and examination that includes a muscu-loskeletal evaluation.

Can shoulder pain occur from a nonshoulder structure? Radicular pain from the cervical spine, cardiac ischemic pain, diaphragm irritation, lung in­flammation, and various upper abdominal pathology all can refer pain to the shoulder.

In the setting of a complete brachial plexus disruption, what is the ideal (most func­tional) way of performing a shoulder fusion procedure? Generally, it is agreed that fixation of the shoulder in flexion, abduction, and internal rota­tion will facilitate function, although the precise degree is debated.

Why does shoulder dislocation occur? The shoulder dislocates because of its unusual anatomy, including lax ligaments, shallow gle­noid cavity, and redundant capsule. Anterior dislocation is more common than posterior dislocation (sometimes seen in electrocution and seizures). The coracoclavicular ligament is usually torn in forcible dislocation of the shoulder.

How is acromioclavicular (AC) pain manifested? Usually, there is a history of trauma, and pain and tenderness are located at the AC joint. Crepitation is elicited by circumduction of the shoulder. Diagnosis and possible relief are gained by intra-articular injection of an analgesic agent. AC joint separation is diagnosed by taking an upper chest radiograph while the patient stands holding > 10 pounds of weight in each hand as arms dangle to the sides.

REHABILITATION OF SHOULDER DISORDERS

What principles are important in rehabilitation after shoulder surgery? Rehabilitation requires a balance between tissue healing and early range of motion (ROM). It is important to understand what has been repaired and what the limits of motion are, as defined by the surgeon. The type of procedure also affects rehabilitation. For example, operations for in­stability (either subluxations or dislocations) can be done through an arthroscope or larger open incisions. Although recovery from an arthroscopic procedure may be shorter due to less soft tissue dissection, the surgical repairs are the same. Consequently, rehabilitation is similar for these procedures.

What therapeutic factors must be considered in the treatment of the painful shoulder? Elimination of pain is needed to assure early mobilization. This is available with nons-teroidal antiinflammatory drugs (NSAIDs) and even intra-articular injections of a steroid. Pendular exercises should be initiated early to prevent capsular adhesion.

How does one treat a stiff shoulder? Nonoperative treatment consists of stretching, decreasing inflammation, and pain relief. To increase motion, aggressive passive ROM is recommended. NSAIDs, pain relievers (narcotic or non-narcotic), and oral steroids are given for pain relief. Operative options include manipulation, arthroscopic evaluation, and release of adhesions. Hospitalization, an indwelling scalene catheter, and aggressive physical therapy may be recommended. Another option is to send the patient home after surgery with immediate physical therapy and nonoperative treatments. Recovery takes 6-12 months.

What is the treatment for rotator cuff tendinitis? Treatment of rotator cuff tendinitis begins with frequent applications of ice, particularly after activity or before bedtime, NSAIDs for 6-8 weeks, avoidance of painful motions, and physical therapy. Exercises should be performed in a pain-free ROM. Focus on stretching to avoid loss of motion and to strengthen muscles. If this does not work, cortisone shots in the subacromial space are recommended. If there is still no improvement, further studies are indicated (e.g., MRI or arthrogram). If there is no rotator cuff tear, surgical treatment involving arthroscopic evaluation with partial acromioplasty should be performed.

What does rehabilitation after acromioplasty entail? Most patients go home the same day with an arm sling and can write or feed themselves in 1-2 days. Lifting anything heavier than a coffee cup is prohibited. The most common complica­tion is a frozen or stiff shoulder. Motion of fingers, wrist, and elbow begins immediately. Structured rehabilitation and physical therapy begin in 7-10 days. If the deltoid muscle was re­moved and reattached, active motion above table level is not allowed for 4-6 weeks. Otherwise, full motion is allowed as pain permits. The goal is full motion in 2-3 months. An acromioplasty with muscle reattachment may take longer.

What about patients with rotator cuff repair?

Rehabilitation after Rotator Cuff Repair

 

 

Elbow, wrist, finger ROM

Passive ROM in abduction in scapular

plane

Passive ROM in forward flexion Pendulum exercises Begin scapular retraction and depression

exercises

Start active-assisted ROM in flexion and

abduction

Active ROM of flexion less than 90° Continue active-assisted ROM Isometric strengthening as tolerated by

pain in flexion, extension, and internal

and external rotation Progressively more vigorous isometrics Progressive isotonic exercises

Active ROM exercises, progressive

resistance, strengthening Stretching in flexion, abduction, and rotation

No weight bearing

No active ROM

Sling or immobilizer at all times except exercise

Avoid arm adduction across body; avoid shoulder extension, internal and ex­ternal rotation as dictated by surgeon

Start active ROM

No lifting of objects causing axial

traction Patient allowed to use arms in front

of body, below shoulder level

Discontinue ROM precautions

How do you treat patients with severe arthritis of the shoulder? Treatment is aimed at maintaining ROM with a home stretching program. Additional thera­pies include ice or heat for symptomatic relief, NSAIDs, and avoidance of painful activities. Cortisone injections are recommended if there is impingement or rotator cuff tendinitis. When nonoperative treatment fails, joint replacement is the best surgical option. Either the humeral head (hemiarthroplasty) or the humeral head and socket/glenoid (total shoulder replacement) can be re­placed. A 1-2-night hospital stay is typical. Rehabilitation begins the day after surgery (see Table).

Rehabilitation after Total Shoulder Replacement

 

Gentle passive and active ROM flexion to full flexion as tolerated, abduction to 90°, internal rotation to 45°, external rotation as dictated by surgeon

Pendulum exercises

Isometric strengthening as tolerated by pain in flex­ion, extension, and internal and external rotation

One-handed ADL

Vigorous isometrics as tolerated

Active-assisted progressing to active ROM

“Wall-walking” with hand used as stabilizer

Vigorous isometrics

Progressive isotonics (e.g., elastic tubing exercises) Active-assisted ROM and active ROM past 90° Two-handed ADL encouraged

Active ROM exercises, progressive resistance,

strengthening Stretching in flexion, abduction, and rotation

No weight bearing

Sling worn at all times except

exercise Avoid active abduction,

extension > 0°, external

rotation as dictated by

surgeon

Continue sling and non-weight

bearing May begin active abduction

May lift objects up to 2 Ibs. Discontinue sling Discontinue ROM precautions

in external rotation Can begin to work on external

rotation

Discontinue ROM precautions

What is the optimum treatment of a frozen shoulder?

• Prevention by early mobilization by pendulum exercises

• Avoidance of splinting

• Minimization of pain and inflammation

Once there is adhesion, active and passive mobilization exercises are effective.

Describe brisement treatment for a frozen shoulder.

Brisement is French for “break.” This implies breaking the adhered capsule. This can be done by manipulation, but brisement includes injection into the glenohumeral joint of a large quantity of an analgesic agent and long-acting steroid in an amount exceeding that permitted by the adhered capsule. The normal capsule admits 30 ml of fluid, and the frozen shoulder admits approximately 3-5 ml.

Discuss rehabilitation after shoulder replacement. External rotation should be avoided for 6-8 weeks. Interestingly, elevation in front of the body does not stress the subscapularis in most cases and can be instituted soon after surgery. Strengthening is important. The most serious complication is infection. Drainage from the wound after 4-5 days is abnormal. If the subscapularis tendon repair fails, dislocation of the prosthesis can occur. Stiffness is common, and most patients do not entirely regaiormal motion.

How do fractures of the shoulder affect rehabilitation? Because treatment often requires immobilization, stiffness and loss of motion may occur. Fractures that do not require surgery are usually stable, and finger, wrist, and elbow motion can begin when pain subsides. Physical therapy including passive, active-assisted motion, active motion, and strengthening should wait until the fracture is healed.

Fractures requiring incision and fixation with pins, plates, or screws can begin motion of the fingers, wrist and elbow in a few days. When the fracture can withstand stress, pendulum exercises should be started, followed by active-assisted motion and active motion. Pain, loss of motion, and poor function should be evaluated with radiographs to check for hardware failure, avascular necro­sis of the humeral head, and proper location of the humeral head in the socket. Sometimes the bones heal in a position that will not allow full motion. Re-evaluation by the surgeon may be necessary.

When is a prosthesis used for shoulder fractures? A hemiarthroplasty (which replaces only the humeral head) is used for severe fractures where the proximal humerus and humeral head are broken into many pieces. The rotator cuff tendons or bones are sewn into holes in the prosthesis. It is critical to allow the tendons or bones to heal before too much stress is applied. A 2-3-day hospital stay is typical. The day after surgery, finger, wrist, and elbow motion can be started. When repair of the tendons is secure, pendulum exercises and pas­sive motion of the shoulder should be instituted. Once the structures heal, more aggressive motion exercises can begin. Loss of strength and motion is common, and many patients do not regain full motion. In this case, an evaluation with radiographs and a neurologic examination are warranted.

What is the treatment for shoulder instability? In some cases, instability can be controlled with muscle strength and careful positioning. Rehabilitation is particularly effective in patients with signs of instability but no history of trauma. Patients with a traumatic dislocation, younger patients (< 25 years old), and athletic indi­viduals have a greater chance of recurrence.

Surgery for instability involves repair of the torn labrum to the glenoid rim (Blankart repair) and shortening of the ligaments (capsular shift). Rehabilitation is similar for both procedures (see Table). Repair of the labrum can be done arthroscopically or with a larger incision. Capsular shifts have been done via an open incision, although some surgeons use arthroscopic techniques. Recently, an arthro-scopic thermal technique performing capsular shrinkage or shifting has been described. A probe heats the ligaments and causes them to shrink and tighten the shoulder. The arm is put in a sling for 3 weeks while the ligaments become tight, then rehabilitation is similar to the open procedure.

 

Rehabilitation after Bankart and Capsular Shift (Open), Bankart and Shift (Arthroscopic), and Thermal Capsulorrhaphy*

 

Passive ROM in abduction in scapular plane Passive ROM in ER to operative limit Pendulum exercises Begin scapular retraction and depression

exercises

Active flexion as tolerated After 1 week, add assisted active ROM for

ER to operative limit Gradually progress to isometric flexion and

ER without weights below shoulder level

Progressive isotonic exercises (e.g., elastic tubing exercises) as tolerated Full ROM forward flexion, abduction Progression external rotation as tolerated

Spinal Traction__________________________________

Ernest H. Winkenwerder, MPT, and Kamala Shankar, MD

Traction is a drawing force, specifically defined by Merriam Webster’s New Colle­giate Dictionary as a “state of tension created by a pulling force exerted on a skele­tal structure by means of a special device.”⁶⁷ In spinal traction, this force could best be described as axial distraction drawing spinal segments apart to achieve a desired physiological end. Applying traction also causes some amount of gliding, especially at the facet joints. Although some recent reviews and studies have called the utility of traction into question,⁶–⁶⁴ spinal traction is still a widely used and touted modal­ity in the treatment choices for physicians and physical therapists.¹¹²¹⁹

This chapter focuses on the methodology of applying effective traction after dis­cussing the indications and contraindications for various conditions. The latest lit­erature and current controversies is reviewed, followed by some personal reflec­tions based on clinical experience.

This critical look is needed because traction varies widely in usage. If five thera­pists or physiatrists were asked about the use of ultrasound for subacute low back strain, each may reach a general agreement on dosage (1.5 w/cm² X 8-10 minutes for six sessions) with comments on the utility or uselessness of the treatment. Each practitioner would probably have a much wider variation in opinion on traction, which Caillet states varies often due to “personal preference and patient response which dictates method, force, duration and frequency of treatment.”⁸

HISTORY

Traction has a long history, with the oldest known reference found in Hindu mythology (3500-1800 B.C.), in which Krishna is found using a stretching technique to correct a hunchback deformity of one of his devotees.³⁸ Traction was described and illustrated by Hippocrates (460-355 B.C.) for conditions of scoliosis and khyphosis.²⁵ In his treatise On Setting Joints by Leverage, he described an extension force that was exerted on a prone patient pulled by ropes attached to levers, coupled with a manip­ulative hand maneuver.⁴⁷ Galen, (a.d. 131-201), a follower of Hippocrates, used axial traction with direct pressure for spinal conditions.³⁸ In 1692, Nuchen used continuous traction with body weight as countertraction to treat wry neck syndrome.²⁴

Modern literature was scanty through the first part of the 20th century. Traction did receive renewed interest after the 1920s as intervertebral disk pathology began to be seen as an etiology of treatable low back pain.²⁴ In the 1950s in his Textbook of Orthopedic Medicine, James Cyriax popularized the use of traction for lumbar disk protrusion.¹³¹⁵ Since then, a number of researchers have investigated the methods and utility of spinal traction. A study of treatment modalities in the Netherlands in 1995 found that traction was used in 7% of the 21 million annual physical therapy treatments in that country.⁶⁴

Continuous bed traction was used for years with very poor results noted by ther­apists, physicians, and patients. This may be one reason why only 28% of physicians surveyed would recommend traction in the case of radicular pain.⁹

161

162    Spinal Traction

Currently mechanical traction is often used in conjunction with other conser­vative treatments,¹⁰‘^45>59>71 but evidence for certain efficacy of traction is scanty.⁶–⁶⁴ Also, new techniques in positioning¹⁷ and equipment⁴⁸–⁵⁹ have appeared over the last 10 years, making assessment of traction more complicated.

INDICATIONS

Traction has been used for conditions ranging from muscle strain to radicu-lopathy. White and Panjabi summarized theoretical and observed changes in the spine with traction as including decreased discal pressure and protrusion, enlarge­ment of the intervertebral foramen, separation of the intervertebral joints (includ­ing facet gliding), stretching of joint capsule, freeing adherent nerve roots, and relaxation of muscle spasm.⁵¹

The “textbook” diagnosis indicating the need for traction is the herniated nucleus pulposus with radiculopathy.¹–⁵–⁹‘²³‘³³‘³⁵‘⁴³‘⁴⁴–⁴⁹‘⁵⁸ Gupta and Ramarao demon­strated decreased disk protrusion in 11 of 14 patients treated with 60-80 pounds of traction using epidurography.²³ Definite clinical improvements were noted in the patients with reduced defects. Another study using epidurography demonstrated that a disk protrusion would flatten with contrast medium drawn back into the disk space under 120 pounds of sustained traction over 20 minutes.⁴⁴

Ramos and Martin obtained negative discal pressures from 100 to 160 mm Hg in five patients with disk herniations at L4-L5 using a VAX-D traction table with 50-100 pounds of traction.⁴⁹ The VAX-D is a split table with a tensiometer in the moving caudal section, which creates distraction in the lumbar spine of a prone-lying patient. In their discussion, they asserted “the only non-interventional method to hold any promise of relieving pressure on vital structures of the lumbar region is that of distraction of the lumbar vertebrae by mechanical forces applied along the axis of the spinal column.”

The intervertebral space including the foramen has been shown to be enlarged allowing less potential impingement of the spinal nerves.⁶¹³ Traction has been found to objectively increase height by 6.6 mm compared to a control group treated the same length of time with passively lying supine in hooklying position.⁴ Traction may be more specifically effective in patients with a so-called soft disk problem (herniated nucleus pulposus) as opposed a to hard disk lesion with bony hypertrophy causing a medial ridge in the vertebra.²⁰ When Christensen and asso­ciates used 35% or less of body weight traction to treat patients with severe low-back pain over 2 weeks, 5 of 12 patients with nonspecific back pain stopped traction treatment owing to increased symptoms.¹⁰ None of the 16 patients with herniated disks on CT scan had adverse reactions to traction therapy.

Spurling’s sign is a nerve root compression test first described in 1944. Distal symptoms are reproduced by extension, side-bending, and rotation to the side of pain, effectively decreasing the space for nerve root egress.²⁰ It is a very specific but poorly sensitive test that, if positive, could indicate the utility of traction, which would open the intervertebral space and decrease nerve root pressure.

Home cervical traction can often be a part of a comprehensive management pro­gram for a cervical disk lesion. Saal and colleagues followed 26 patients treated non-surgically for disk lesions, all of whom received home cervical traction.⁵² They found

Spinal Traction    163

good to excellent outcomes in 20 patients, with 21 returning to their same job. Ten of these patients had disk extrusions. Another retrospective study of 88 patients in a 3-year period found 87% of those with mild to moderately severe cervical spondy-losis (Quebec whiplash criteria) had relief after 3-5 minutes of properly applied home cervical traction.⁵⁸ Other studies related good relief with traction.¹‘¹⁴

Beurskens notes that it is often difficult to distinguish among disk, facet, or mus­cular etiologies ionspecific back pain.⁶ Traction has been shown to stretch the facets through gliding³⁵ and separate the apophyseal joints.¹³ Appropriately strong traction may rupture adhesions,³⁵ release adhesions in the dural sleeve,⁵⁰ and aid in stretching ligaments via physiologic creep.²⁶

The relief of muscle spasm may be another indication for traction. Muscle relax­ation, which occurs during traction has been postulated to occur through fatigue.¹⁸ Hood found surface electromyography (EMG) activity increased during traction on the lumbar spine, but then the activity decreased toward resting levels after 7 minutes.²⁸ Leutchuman and Deusinger analyzed the sacrospinalis muscle at L3-L4 in patients with low back pain and found muscle activity decreased with time over traction.⁴¹ More than 50% of patients in the study reported relief with traction.

Traction has also been used empirically for pain control to allow a greater tol­erance for rehabilitative exercises.⁵² In a randomly controlled trial of 35 men and 65 women, patients given traction had improved cervical range of motion and improved flexion and rotation and required fewer pain medications taken and fewer cotreatments or interventions.⁷³ In a review of the primary care work-up of elderly patients with neck pain, Kriss and Kriss noted that traction was helpful for some patients.³⁷ Traction has been used specifically in chronic headaches,³ espe­cially after whiplash injury,⁴⁵ with suboccipital musculature relaxation or elonga­tion being the effect desired. Stone and Wharton used a combination device that delivered traction, transcutaneous electrical nerve stimulation (TENS), and mas­sage, obtaining subjective relief of tension headaches.⁵⁷

Wells details the condition of “cervical angina,” chest pain mimicking angina with the pain-generating organ most commonly the C7 nerve root. If coexisting coronary artery disease is ruled out, the patient may benefit from intermittent cer­vical traction.⁶⁹

The effect of decreased pain may be related to improved vascularity, which serves to decrease inflammation at the nerve root.²⁹ Another potential pain-relieving mech­anism is the probable stimulation of large afferent nerve fibers of the muscle and joints that presynaptically inhibit pain fiber transmission at the spinal cord level.⁷¹

Lastly, traction may act to promote general healing.³ In animal models of the hip and knee joint, distraction was found to decrease inflammation and the level of abnormal proteoglycan metabolism characteristic of osteoarthritis.

CONTRAINDICATIONS AND PRECAUTIONS

Traction is a very safe modality in the absence of contraindications. Frazer reported an incidence of “untoward sequalae” in 6 out of 25,000 patients (0.02% ).²² The pulling weight capable of creating potential ligament disruption in the cervical spine is 120 pounds,¹² which is well below the usual effective dose of 20-40 pounds of cervical traction.

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Traction is contraindicated in the presence of any structural disease secondary to tumor or infection.⁵⁸⁷² Any instability in which movement would be contraindi­cated, such as significant spondylolisthesis, prohibits traction.⁷² Rheumatoid arthri­tis with suspected atlantoaxial subluxation is an absolute contraindication.⁵³ Flex­ion-extension films should be reviewed before commencing traction if any occult instability is suspected.

Myelopathy,⁵² a neurogenic bladder from cauda equina syndrome,⁵³ and a mid-line disk herniation that may worsen with traction³² are contraindications. A person with Lermitter’s sign (described in 1932 as an electrical shock sensation felt in the lower extremities when the neck is flexed) should not receive traction.²⁰

Vascular compromise, particulary in the cervical region at the carotids or vertebral arteries, is a contraindication to traction.⁵⁸ Positive Doppler studies, carotid bruits, and any dizziness or adverse symptoms with Spurling’s movement advise against traction.

Patients with abdominal problems such as hernias or peptic ulcers may have problems with lumbar traction.⁵³ Also, tight pelvic and chest straps may decrease venous return and restrict breathing. Although it is a relative contraindication, claustrophobia may be a real limiting factor to an effective traction dosage for some people. Pregnancy and osteoporosis, depending on the extent and individual con­dition, may be a relative or absolute contraindication in those individuals affected.¹

Traction in the first few weeks of an injury may do more harm than good accord­ing to some writers,¹⁹⁵⁸ especially if the patient has an acute torticollis.³² Patients with temporomandibular joint dysfunction may have jaw aggravation with the chin straps on some traction units,²¹ especially if they are using home traction with too much weight or at an ill-advised angle.⁵⁵

Last, a relative contraindication is accompanying low-back pain. Seated cervical traction posture may aggravate an existing back condition.⁵⁸ In a 2-year retrospective study, LeBanet al. noted significant low back pain in 12 of 2200 patients treated with cervical traction of 15-30 pounds.³⁹ The patients with an earlier history of low back pain, relatively quiescent, developed a positive straight-leg raise on the symptomatic side. LeBan referenced cadaver studies demonstrating traction at the neck stretched the dura down to the level of the sacral nerve roots. He postulated that the increase in lumbar pain was due to nerve root tethering distal to the traction force (Table 1).

TYPES OF TRACTION AND METHODOLOGY

This section will review the types of traction available with methodologies dis­cussed using the most common techniques of motorized traction in the physical ther­apy clinic. Studies are cited both to demonstrate the wide variety of application and to provide a sense of common agreement across studies and practices as they occur.

Manual and Positional Traction

Manual traction is delivered with the therapist stretching the spine using his or her own body weight.¹–⁶¹⁶⁵⁸ It is viewed as a form of spinal manipulation by Tan and Nordin, who classify it as a nonthrust technique, usually referred to as a mobiliza­tion in that it does not involve high-velocity at low-amplitude motion.⁵⁹ They prefer supine manual traction to mechanical traction and state that mechanical traction should be used only if manual traction is ineffective.

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Table 1. Summary of Indications and Contraindications for Traction

Indications

Decrease diskal pressure and disk protrusion

Enlarge intervertebral foramen and relieve impingement

Improve facet hypomobility

Stretch the joint capsule

Free adherent nerve roots

Relax muscle spasm

Assist in pain control

Contraindications and Precautions

Structural disease due to tumor or infection

Instability such as spodylolisthesis

Myelopathy and neurogenic bladder from cauda equina

Midline disk herniation

Cardiovascular disease

Claustrophobia

Pregnancy

Osteoporosis

Acute injury

Any patient with adverse reaction to treatment

Previous spinal surgery

Spinal tumors

Cyriax used manual traction extensively as an adjunct or precursor to manipu­lation.¹⁶ “Taking up the slack” in a joint allows the practitioner to assess the degree of hypmobility and more specifically stretch the desired spinal segment. Harris states that traction may be the most important part of a manipulative maneuver.²⁴

Manual traction is also used to test tolerance of a patient for mechanical trac­tion. The practitioner can also apply distraction at varied angles to find the most comfortable or effective postion for mechanical traction.⁵⁵

Abdulwahab advocates manual cervical traction specifically for cervical radicu-lopathy.¹ Paris uses manual lumbar traction to treat a herniated disk.⁴⁶ A simple application of this technique for unilateral radiculopathy is known as a leg pull. Bradnamet al. noted decreased excitability in alpha motor neurons with manual traction.³ They studied the H-reflex curve and used nontraction manual contact in their control group.

Positional distraction is a technique taught to patients which may be used at home. The patient lies on a bolster or other object in the sidelying position, with the affected side up, creating side-bending away from the impinged site.⁵⁵ A 6- to 8-inch bolster is sufficient, and rotation away from the affected side may be added to open further the facets and stretch the musculature. Paris recommends begin­ning the posture at 5 minutes’ duration and progressing up to a maximum of 40.⁴⁶

Continuous Traction

Continuous traction was used in the past in patients hospitalized with acute low-back pain and used very light weights of 20 pounds or so and was completely ineffective in separating vertebrae.³⁴ The unspoken rationale behind the treatment was often to encourage bed rest in the patient. Prolonged weighdessness is believed to be a cause of back pain in astronauts.⁴¹ The move toward early mobilization and weight bearing for

166    Spinal Traction

optimal return, coupled with decreased reimbursement for acute hospital stays for low-back pain, have eliminated continuous traction from the current clinical scene.

Gravity and Inversion Traction

Gravity lumbar traction in a tilted bed or table uses 40% of the patient’s body weight (the lower trunk and legs) as the tractive force.⁷ Inability to vary the force and discomfort of the restraints over a prolonged session are limiting factors. Inver­sion traction is sometimes difficult to get positioned into and may put undue stress on the cardiovascular system.⁴⁰ Again, the force is not easily increased or decreased outside the effects of gravity on the patient’s upper body, and the prolonged upside down posture can be uncomfortable.

Motorized Traction Static or Intermittent?

After selecting motorized traction as a treatment, the clinician is faced with the decision as to whether static or intermittent traction will be more efficacious (Table 2). In general intermittent traction has been favored in the United States, and static traction is the preference in Europe.⁵⁵

Colachis and Strohm found no significant difference in tolerance and effect between static and intermittent traction iormal subjects.¹³ In a controlled study of 100 patients, Zylbergold and Piper noted with blind observers that range of motion improvements in the cervical spine were better after intermittent than static traction.⁷³ Leutchuman and Deusinger noted greater treatment tolerance in an intermittent pelvic traction group.⁴¹ In their study, 30% of patients undergoing static traction had increased post-traction pain (two with a severe increase) com­pared with 15% in the intermittent traction group. Those with adverse reactions to intermittent traction recovered faster, with diminution of increased symptoms to baseline 2 hours or less after traction.

Table 2. Important Variables in Standard Traction Application

1. Static or intermittent?

Dynamic pumping to affect disk or steady stretch for ligaments andfacets Comfort of patient

2. Position?

Supine, prone or seated

Supine best for cervical traction

Prone may be used for disc patients with better effect

3. Angle of pull?

Greater flexion produces greater distraction and opening of intervertebral foramen, but may increase muscle tension in cervical spine. Greater extension creates more distraction in the upper cervical spine at the OA joint.

4. Weight?

Heavier weight needed to distract disk and hypomobile facets

Lighter weights may be more appropriate for more irritable/acute states, for pain and edema

control More comfortably tolerated

Spinal Traction    167

On the other hand, Cyriax favored static traction, noting muscular fatigue after only 3 minutes of static traction.¹⁶ He theorized that intermittent traction for relax­ing musculature was ineffective because it might excite only the stretch reflex of the sacrospinalis muscle.

If intermittent traction is chosen, the traction cycle can vary from a 7- to 10-second hold with a 5-second rest to a 30- to 60-second hold with a 10- to 15-second rest over a 15-30 minute treatment.¹³ Leutchman and Deusinger used pelvic trac­tion with equal periods of 10-second hold and 10-seconds rest.⁴¹ Colachis and Strohm found that varying the duration of hold from 7 to 30 to 60 seconds made no significant difference in the amount of distraction measured for cervical trac­tion at a constant angle of 24° flexion.¹²

The anatomic structure involved may play a part in the decision of hold time. Stretching ligaments and muscles may be done more easily with a longer hold of 20-30 seconds, as in a traditional stretch, whereas changing the fluid dynamics in a disk may call for a more rapid rhythmic pattern.

Frequency of Treatment

Frequency of treatment depends on patient response. If the disk does indeed quickly revert to herniation shortly after the traction session (noted on epidurog-raphy) ,⁴⁴ then daily treatments with postural correction and support of active exer­cises as part of an overtreatment plan may be most effective.⁴⁹ Zylbergold and Piper used 10-15 traction sessions over 3-4 weeks.⁷³ Saunders successfully treated a hypo-mobile lumbar facet with four sessions involving traction.⁵⁴ Jackson claims that relief should be obtained within 15 treatments.³⁰

Lumbar Traction on a Table

To be successful, traction must generate sufficient force to overcome properly muscle contraction, spinal curvatures, ligamentous resistance, and friction of the body on the table.⁶ At least one half of the body weight on a friction free table is recommended by Judovich.³³ On a flat table, the friction resistance of the body is considerable. A split table decreases the force necessary for traction from 300-400 pounds down to 80-100 pounds.¹²

The amount of force needed to distract the lumbar spine varies from 70 to 150 pounds, according to a review by Pellecchia.⁴⁸ Cyriax noted definite movement of lumbar spinal segments at 120 pounds in a 25-minute period.¹⁵ One hundred pounds was the average used in several other traction studies.²⁷‘⁴⁸‘⁵⁴

Positioning of the patient is very important for successful lumbar traction. The supine hook-lying position is standard (Fig. 1) with 70° of hip flexion and 18° of angle for the best separation of the vertebral bodies.¹³ The patient should be com­fortable, because narrowing of the intervertebral spaces has beeoted in traction with muscle guarding when the patient cannot relax.¹⁷ A protective scoliosis should be respected, with the gradual resumption of midline posture when tolerated.⁶⁶ The straps should be tight to eliminate slipping and placed against the skin with a protecting towel for sanitary reasons. The pelvic belt should overlap the thoracic belt around the lower ribs and should have good purchase on the iliac crests.

A safety release and cutoff switch should be close at hand for the patient to ter­minate the treatment, if needed. The patient will, of course, be advised of the treat-

Figure 1. Supine traction in semi-fowler position. Note angle of pull, split table, and safety switch in patient’s hand.

ment goals and what to expect from the treatment with the understanding that he or she can terminate the session at any time. Traction should be applied smoothly after all slack is taken out of the system and friction is minimized. It is always a good idea to do the first session as a trial treatment at the lower end of the therapeutic range to assess patient response and progress as indicated and tolerated (see Fig. 1).

Prone Pelvic Traction

Prone pelvic traction is a variation on supine traction with the same goals and general guidelines. It is favored by Saunders⁵⁵ and is the position for the VAX-D traction machine.⁴⁹ The neutral spine is favored in prone traction with a straight pull generally and may be tolerated better in patients who get posterior disk move­ment in the hook-lying position.

When Humphreys looked at the foraminal space at C5-C6 in traction, he found that traction did not significantly increase the foraminal opening to any additional amount after simply flexing the neck. A correlation was found, however, ieutral, where traction caused a vertebral separation.²⁹ A neutral spine posture in traction places less load on the posterior components of the back and is favored in the prin­ciples of McKenzie.⁴²

For proper prone traction, no spreader bar is placed and the patient puts his or her legs through the pelvic straps. The table is raised or the pully is adjusted to effect neutral extension (Fig. 2).

Cervical Traction

More studies have been conducted on cervical traction, and it is generally more widely in use, than pelvic traction. This may be due to the observation that it is easier to set up, with only 7% of friction free body weight required for a physiologic response.¹⁷ It takes 10 pounds offeree to overcome the weight of the head,³⁰ and 25 pounds has been mentioned as the minimum needed for vertebral separation.³⁰³² Thirty pounds has been used by several practitioners.¹¹¹⁸ Judovich found improve­ment in more than half of 60 patients studied using forces between 25 and 50

Figure 2. Prone pelvic traction. Note no spreader bar and neutral spine position assisted by pillows, straps between patient legs.

pounds.³² In some patients, pain was increased at 25 pounds but decreased at 35 pounds. Harris used only 15 pounds and achieved relief in patients with whiplash.²⁴ He treated the patients with three 5-minute cycles of sustained traction, along with moist heat, and allowed the patients to rotate their neck gently during treatment.

Twenty-five degrees to 30° of flexion straightens the normal cervical lordosis, and Colachis and Strohm noted greatest separation at the largest angle (6°, 20°, and 24° degrees were assessed) .ⁿ To stretch the upper spine and subocccipitals, a more neu­tral posture is used. Excessive extension and compression are to be avoided.

The supine position is generally preferred over sitting¹¹¹⁷‘²⁵ because the patient is more comfortable and the weight of the head is neutralized. It is important for comfort to avoid pressure over the chin if a chin component is part of the head halter (Fig. 3).

New Types of Traction

Several new traction tables and devices are being used currently.¹⁸²⁶‘⁴⁹‘⁵⁷ In the VAX-D traction device, significant drops in intradiscal pressure have beeoted, along with symptomatic relief.⁴⁹

Autotraction is an active technique that seeks to restore normal posture. It was developed by Lind in 1974 and improved by Natchev in 1984. A specialized table and patient training are required.⁵⁹ Recently, traction was coupled with an EMG mecha­nism and a feedback loop. This allowed more rapid progression of a traction protocol by dynamic adjustment of tension in response to muscle EMG in a treatment session.⁷¹

Home Traction

Traction can used as a home treatment in conjunction with exercises for better resolution of neuromusculoskeletal complaints. Pelvic traction is available but is not as common and is more expensive than a simple home cervical traction kit. These kits use a water weight bag up to 20 pounds in an overdoor position.¹‘⁵²–⁵⁸ A simple buckle and web device with a pulley can convert the traction to supine, and a pull bar can be incorporated so the patient can simulate intermittent traction at

Figure 3. Supine cervical traction. Note comfortable lumbar position, angle of pull, and no stress on jaw with head harness apparatus.

home. The Saunders home traction unit relies on a pneumatic pump in the supine position with no strap over the chin.

CONTROVERSIES IN TRACTION USE

Despite, or perhaps because of, the wealth of literature and clinical practice with traction, traction remains a somewhat controversial treatment choice for spinal conditions. Opinions vary as to its utility, ranging from a integral part of rehabili­tation⁵² to a strong negative reaction. After a review of 31 articles, the U.S. Depart­ment of Health and Human Services stated in a report that “spinal traction is not recommended in the treatment of low back pain.”⁶³ Traction is considered an addi­tional trauma to a healing system by Weinberger.⁶⁸

Tan and Nordin state “empirically mechanical traction should only be started if active modalities and manual traction have not achieved the desired end.”⁵⁹ One difficulty with this position is that if traction is the treatment of choice after all other conservative measures have failed, subjects for traction are those most recal­citrant to treatment and are more likely to fail any additional modality.

In a study published in 1990, 369 orthopaedists and 165 physiatrists were asked if they would use traction in a hypothetical case of a 42-year-old man with acute bilateral low back pain without evidence of radiculopathy.⁹ Sixteen percent of those responding stated that they would use traction for nonspecific acute pain and 27% would use traction for a herniated disk. Of those respondents favoring trac­tion, 78% gave nonphysiologic rationales for use (54% to reinforce bed rest and 27% to give psychological support). Seventeen percent did say that they would use traction to decrease nerve root or disk pressure, but the general consensus was reminiscent of the days when continuous traction was in vogue, and the survey writ­ers stated that traction was only delaying recovery by promoting deconditioning and atrophy, and reinforcing passive health-care behavior.

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Studies of traction are often fraught with problems. In a review of 21 papers reporting 24 studies, a 100-point scale was assigned to assess the strength and valid­ity of the study (e.g., double-blinded, specific protocol, adequate sample size).⁶⁴ Only three studies assessed received over 50 points, and these three showed no improvement with traction in pain, mobility, functional status, or other symptoms.

Beurskens did a pilot study of 28 patients and found a recovery rate in a high traction group of 64% compared with a sham traction group.⁶ This study was repeated in a larger trial of 100 patients, and he found no significant differences between the two groups. Both groups did improve over the study.

Humphreys found that traction did not add any additional distraction effects over simply flexing the neck iine cadaver spines.²⁹ As all the musculature had been stripped away, this in vitro study may not have taken into account all the struc­tures traction affects in vivo. The effect of traction on muscle activity is still in con­tention. Hood noted no myoelectric activity in patients without low back pain in supine hook-lying position.²⁸ After 3-7 minutes of traction, muscle activity increased. It is difficult to speculate on what this could mean for patients with low back pain. The observation that traction has some effect oormal subjects may be the equivalent of saying ibuprofen can cause stomach upset iormal subjects without any inflammation. Using EMG and traction, Wong noted a decrease in muscle activity in both normals and in patients with cervical radiculopathy.⁷¹ A greater decrease was noted in those subjects with high initial resting muscle activ­ity. This indicated a good response to the traction modality.

Some studies that show no change with treatment may be flawed in the use of the modality studied. Klaber-Moffett and colleagues noted greater muscle relax­ation in patients treated with 2 pounds of placebo traction versus 6-12 pounds treatment weight.³⁶ One study using traction as part of a total program for cervical radiculopathy used only 5 pounds of weight.⁵ Clearly, if traction is to be accepted or discarded, the decision should be based on both clinical observation and stud­ies that use the modality in its most optimum parameters.

Traction is often used for pain control so that the patient may more rapidly progress in functional exercises,²⁰⁵² but the mechanism of pain relief is still in ques­tion. Although some patients get relief for 24 hours or more after traction, disk bulges recur rapidly on epidurography, often within an hour.⁴⁴ Although many people obtain relief with auto-traction, the level of disk prolapse remains the same.⁶¹

In critiquing a study of autotraction, Trudel alluded to the problem of defining the pain generating organ in treating low back pain.⁶² Objective findings are often present in overlapping conditions, and many abnormal findings are present in normal subjects without radicular pain.

It may be that the wrong subset of patients is being evaluated for traction. If trac­tion benefits soft tissue structures other than the disk, perhaps more study should be directed to patient populations without radiculopathy.¹⁶ In the case of degener­ative joint disease, some structures must be reduced or realigned to provide relief obtained with traction.

Jensen postulates that improvement may be due to change in tissue damage around the herniated material and not the movement of the herniated material itself.³¹ This brings up the question of whether pain is mechanical or chemical in nature. If the traction improves blood flow to decrease edema around the disk,

172    Spinal Traction

then whether the disk is truly reduced may be less an important question than assumed. Also, traction may work at least partly by the mechanical stimulation of large sensory nerve fibers in accordance with the gate theory of pain relief.⁴¹

The difficulty of relating improving symptoms to changing physiologic effects may be seen in the “release phenomenon.” Also known as a “rebound phenome­non,” it occurs when a patient notes a significant increase in pain, often at the end of a traction session, when he or she is rising from the table. This is seen as a con­traindication to continuing further traction sessions and has been thought of as a sort of “rebound” of disk material back onto the nerve root after distraction. Paris, however, states that it may be a positive sign when pressure is released from a neu-rovascular structure and is a result of revascularization.⁴⁶ Cyriax described this in thoracic outlet syndrome. Although Paris states that the physician should proceed judiciously, the symptom of increased pain (e.g., sensation) may be a very positive indication of traction’s beneficial effect.

The problem of ascertaining the efficacy of traction is complicated by the many cointerventions often performed along with traction (other modalities, exercises, corsets or supports, and injections besides any medication or activity changes a patient may make) over the course of treatment.⁶² Although these may mitigate or reinforce the effects of traction, any study that focuses only on traction as a sole intervention will not show any lasting relief. Certainly, any patient treated with diabetes would not expect to get improvement on medication alone but would want to incorporate diet control, weight loss, and other measures such as good skin care for total management. Likewise, a patient obtaining improved spinal elongation and disk reduction with traction should receive immediate instruction in maintaining neutral posture and stabilization exer­cises, along with passive support as needed. Saunders emphasizes this point that man “cannot get well on traction alone. [He] must have total management.

 

_{Joint Mobilization}

Ida Hirst, PT

When the normal mechanics of joint motion are altered, pain and early signs of joint degeneration often occur. This chapter explores the effects of altered mobil­ity, reviews normal joint function, and provides basic information on appropriate treatment techniques that can be applied. The word manipulation has been used loosely in medicine to mean passive movement of any kind. In this chapter, manip­ulation will be defined as a sudden movement or thrust, of small amplitude, per­formed at a speed that renders the patient powerless to prevent it.⁹ Joint mobiliza­tion is defined as passive movements performed in such a way that, at all times, they are within the control of the patient so that he can prevent the movement if he so chooses. Joint mobilization techniques are applied in the presence of restricted joint motion. The practitioner must make certain, however, that a painful joint exhibits restriction of the capsule and requires mobilization. Often, active range of motion is limited or painful, but the cause of the limitation is found in other peri-articular structures. The effective examination procedures to make an accurate diagnosis and to provide the most effective treatment are covered.

HISTORY

Much literature is available on various techniques and methods of joint manip­ulation and mobilization. Important contributors include Cyriax, James and John Mennell, Maitland, Kaltenborn, and Cookson and Kent.²³⁶–⁹–¹¹¹²

For a period of time, the use of passive mobilization techniques almost became a forgotten art. This is thought to be a result of the techniques provoking pain when they were used too aggressively. Maitland contributed tremendously to the advancement of standardized educational programs and tutelage available to phys­ical therapists and other members of the medical community, teaching safe and gentle treatment techniques around the world.⁹ This in part has helped to make these techniques popular once again.

Controlled studies on the effectiveness of joint mobilization have been few.¹⁴ The primary evidence for the efficacy of this type of treatment comprises clinical experience, case histories, and inference.⁵ Further controlled studies are necessary to assess the benefits of joint mobilization.

PHILOSOPHY OF JOINT DYSFUNCTION

Joint injury, including conditions, such as osteoarthritis, instability, and the after effects of sprains and strains, are not diseases but dysfunctions. These dysfunctions are manifested as either an increase, a decrease, or abnormality of motion.

When the dysfunction manifests as limited motion, the treatment of choice is mobilization of joint structures, stretching muscles and fascia, and sometimes strengthening of muscles. When the dysfunction is manifest as increased move-

177

178   Joint Mobilization

ment, laxity, or instability, the treatment is not mobilization of the joint in question but stabilization. This may be accomplished through correction of joint limitations in neighboring joints that may be contributing to the joint’s need for compensa­tion or through postural training and exercise.

Joint dysfunction responds well to conservative treatment. Even after degenera­tion has occurred and resulted in a loss of joint space, cartilage can be made to regenerate by removing restrictions, stretching the joint capsule, and promoting normal and frequent use.¹

The effects of continuous passive motion (CPM) have been studied on the heal­ing of full thickness articular cartilage defects. Salter et al. published the results of experimental continuous passive motion on defects in the distal joint surfaces of the femur in 20 immature rabbits. With continuous passive motion, healing through the formation of new hyaline cartilage (chondroneogenesis) occurred in over half of the induced defects within 4 weeks.¹⁵

EFFECT OF IMMOBILIZATION ON ARTICULAR AND PERIARTICULAR STRUCTURES

Each structure responds uniquely to immobilization. It is important to under­stand each structure’s response to effectively manage the patient during the reha­bilitation process.

Cartilage

Cartilage does not have a direct blood supply. It relies on the compressive and distractive forces of joint motion to obtaiutrients and oxygen. When a joint is immobilized, the cartilage weakens and begins to lose its stiffness and resilience to compression. Areas in which the articular cartilage does not make good contact with the articular cartilage on the opposite joint surface develop fibrous changes, or pannus formation, and loss of cartilage results. This accounts for the loss of vertical height in the joint space with degenerative changes. Radiographs exhibit degener­ative changes including spurring after as little as 4 weeks of immobilization.⁴

Synovium

In 2 weeks of immobilization, the blood vessels in the subsynovial region prolif­erate, and increased synovial fluid is produced. After 4 weeks, there is a marked increase in the number of synovial cells, hyperemia is present, and pannus begins to form over the noncontact articular cartilage. Within 6 weeks, the amount of fibroblasts and collagen within the joint increases, giving a fibrotic appearance.¹

Joint Capsule

The joint capsule begins to show signs of increased thickness after 5 weeks of immobilization. Folds of capsular tissue adhere to each other and further restrict

Ligaments and Tendons

Disuse atrophy of the surrounding ligaments and tendons occurs. The tensile or breaking strength reduces, and the strength of the structure’s insertion at the bone

Joint Mobilization    179

diminishes. Ligaments demonstrate a decrease in fiber bundle thickness. Tissue samples taken from immobilized sites are found to have a reduced amount of aer­obic enzymes.¹

Bone

Bone density is maintained through weight bearing. Weight-bearing bones require at least 2-3 hours of vertical weight bearing each day in order to maintain density. After a period of immobilization when weight bearing is prohibited, the capacity of the bone to withstand stress is diminished.¹

Muscle

Similar effects take place at the voluntary muscle groups surrounding the involved immobilized joint. Muscles atrophy, vascularization decreases, and fuel stores and mitochondria within the muscle decrease. The aerobic capacity dimin­ishes, there is loss of volitional control of the muscle and the capacity to withstand tensile forces reduces.¹

Not all of these structures recover at the same rate. During the rehabilitation process the program must be adapted to allow recovery of the lowest metabolic sys­tems first, progressing over time to the higher metabolic systems.

JOINT MOBILIZATION AND CLASSIFICATION OF MOVEMENT

There are five classifications of joint movement as outlined by Dr. Mennell.¹¹

1.  Active joint movement. These are the classical gross motions taught by
anatomists, or joint motion that can be actively performed by a voluntary muscle.

2.  Passive joint movement. The movement in which a joint is passively put
through the range of motioormally under voluntary control.

3.  Joint play movement. This movement is not under voluntary control but is
necessary for the performance of painless, free, voluntary movement. Examples of
these motions are long axis traction, rotation, anterior and posterior gliding, and
medial and lateral gliding.

4.  Articulary movement. This is also a nonvoluntary motion. A joint with limited
joint play is taken through the full range of motion, and then a series of passive,
rhythmic repetitions of movement are applied by a practitioner to restore normal
synovial joint play movement.

5.  Specific joint manipulation. This movement describes the action in which a
joint with limited synovial joint play is taken through the full range of movement
present, at which point a manipulative thrust is applied to restore the full normal
range. Full joint play allows pain-free active motion.¹²

Traction

The use of traction is an important component of manual therapy. The force of pull is determined by the purpose for which the traction is being applied. The manual therapist Kaltenborn describes three stages of traction⁶: •   Stage 1 traction (piccolo). The traction is so small that only the compressive

effect in the joint is released while the joint pressure is neutralized. The joint

surfaces are not actually separated.

180   Joint Mobilization

•    Stage 2 traction (“taking up the slack”). The joint is distracted using little force
to separate the joint surfaces just as far as the soft tissues allow.

•    Stage 3 traction (mobilization treatment). A continuation and extension of the
stage 2 distraction of the joint is applied with enough force to stretch the soft
tissues.

Traction is used as a treatment for the relief of pain, and for this reason it is best to use either stage 1 or stage 2 . The traction is held for approximately 10 seconds, with a rest of 2-3 seconds before repeating.⁶

Compression

When symptoms from a joint surface disorder are present, joint compression is used both to test and to treat certain disorders. When symptoms can be repro­duced with joint compression, treatment can include compression to a degree that does not provoke a painful response. The compression is combined with oscillat­ing movements to the joint back and forth for 1 or 2 minutes. As the joint responds favorably to the treatment, the degree of compression can be progressed. This has been especially beneficial in the treatment of patellofemoral joint disorders.⁹

Joint Positions

The term Opposition is used to describe the anatomically defined basic position or “normal” position as a basis for the measurement of joint movement. This is dif­ferent from the resting position. Resting position is the position where the joint cap­sule, ligaments, and muscles related to the joint are most relaxed and where the joint capsule gives the most amount of space. The close-packed position, on the other hand, is the position in which the capsule and ligaments are in maximal tension. It occurs at one extreme of the most habitual movement of that particular joint. In this position, the concave and convex joint surfaces are in complete congruence and the two bones of the articulation cannot be separated by traction.¹¹

Planes and Axes of Movement

When performing and teaching joint mobilization, the axes of motion must be understood, as must the plane in which the motion is performed. The four planes of motion are as follows :

Median plane—Divides the body vertically into two “equal” lateral parts Sagittal plane—Any plane parallel to the median plane

Frontal (coronal) plane—Divides the body vertically into an anterior and poste­rior part

Horizontal plane—Divides the body across into an upper and lower part Each plane has two main axes that run at right angles to each other. When the mobilization is applied to the joint, it is applied as a movement of trac­tion, translation, or rotation. Traction separates the two joint surfaces perpendicu­larly. With translatory movement, all of the points on the moving articular surface move in the same direction at the same rate of speed. With rotatory movement, the farther a point on the articular surface is from the axes of motion, the greater the speed of motion and the greater the distance covered. Examples of rotatory movement are passive and active joint motion.

Figure 1. The bone on the left is the side being stabilized. The bone (or extremity) on the right is the side receiving mobilization. The large arrows indicate the direction the extrem­ity is moving. The small curved arrows depict the direction that the joint surface needs to go to accomplish this movement. The convex surface is moved in the opposite direction of the bone movement (top). The concave surface is moved in the same direction as the bone movement (bottom).

Direction of Treatment

The direction of treatment is determined by the shape of the joint surface being mobilized. One surface is always considered concave and one considered convex. The axis of motion is always found on the side that is convex (Fig. 1).

The principles to remember are:

•   When mobilizing a concave joint surface on a convex joint surface, mobilize in
the same direction the bone or extremity is trying to go.

•   When mobilizing a convex joint surface on a concave joint surface, mobilize the
joint surface opposite the direction the extremity is trying to go.⁸‘⁹

TREATMENT SEQUENCE AND PRINCIPLES OF TECHNIQUE

1.    Communication. One of the most important contributions practitioners can
make to the successful management of a patient’s symptoms is taking time to
understand the patient. Verbal and nonverbal communication must be considered
to understand the patient’s complaints clearly. This information must be corre­
lated with the objective findings of the examination and used to assess the effec­
tiveness of the chosen treatment.⁹

2.    Patient positioning.  The  patient  must be  positioned  in  a  comfortable
manner, with the extremity relaxed and properly stabilized. The patient must have
complete confidence in the therapist’s grasp, and the position should take full
mechanical advantage of levers.

3.    Therapist positioning. The therapist also must be positioned correctly for
successful mobilization with good technique. Without correct positioning, the
therapist will fatigue rapidly, and the intended result will not be achieved. Wher­
ever possible, the therapist should embrace the parts to be moved or stabilized. In

182   Joint Mobilization

addition, the therapist should hold around the joint so as to feel the joint move­ment as the technique is performed. The therapist’s position must afford complete control of the movement, and the patient must feel confident that the joint will not be hurt by being moved further than he or she expects.

4.    Stabilization. It is important to determine which joint surface is to remain
stable and which is to be moved. If proper stabilization is not achieved, the treat­
ment may provoke pain.

5.    Direction of treatment. Ideally, mobilization is initiated from the resting posi­
tion. Sometimes, however, this must be modified to treat in the position in which
there is the least amount of pain. The structure of the joint surface determines the
direction of treatment. It is advisable to begin with joint traction, which reduces
joint contact, followed by movement parallel to the joint surface. The direction
should first be toward the motion least impaired, followed by that which is most
impaired.

6.    Taking up the slack. The joint play movement is taken up with direct and
steady pressure in the direction you wish to treat.

7.    Mobilization. Articulary mobilization  consists of repeated,  nonvoluntary
movements applied by a skilled therapist. The motion applied begins from the
joint’s resting position and continues to the position where the slack is taken up,
and then back again. The degrees or “grades” of mobilization pressure applied are
discussed later in this chapter. Any part of a range of movement may be used in
treatment, and widely varying amplitudes and speeds may be chosen. A painful
joint is best treated with a slow, smooth, even rhythm; whereas a stiff, small joint is
treated best with sharp, staccato type movements. Some patients have difficulty
relaxing completely, even when pain is minimal. If large-amplitude treatment
movements are hindered because of this, a “broken rhythm” can be used with
varied amplitude in an attempt to trick the muscles.

When attempting to increase the range of movement in a stiff joint with pain pres­ent at the extremes of motion, passive stretching is applied slowly up to the point that pain becomes a limiting factor. This position is held until the pain subsides, after which an additional slow stretch is added until the pain increases again. Small, slow, oscillatory movements are then applied just short of this new limit of movement.

The initial treatment must be performed in the painless part of the range in one of the least painful directions. The number of oscillations given is determined by the degree of irritability present. The average time spent passively moving joints that are not excessively painful is approximately 4-5 minutes. A highly irritable joint should be moved less with the treatment time anywhere between 30 seconds and 2 minutes.

8. Testing. Both the voluntary active (or passive) range of motion and the non-
voluntary range of motion, also known as the joint play, should be tested for the
effectiveness of the treatment after an articulary mobilization procedure has been
completed.⁶⁹

New Technique

Brian Mulligan, a physical therapist from New Zealand, has recently popularized a relatively new technique for joint mobilization that can be applied to spinal and

Joint Mobilization    183

peripheral joints.^13a He has called these techniques natural apophyseal glides (NAGs), sustained natural apophyseal glides (SNAGs), and mobilization with movement (MWM). With these techniques, the therapist manually sustains pres­sure in a lateral glide, rotatory glide, or otherwise while the patient actively moves the joint into the direction in which increased movement is desired. Although research to prove the effectiveness of these techniques has not been completed, Mulligan believes that they improve the mechanical position of the joint allowing for pain-free motion, thus restoring the mechanical ability of the joint to move throughout its normal range. After moving repetitively (usually 3 sets of 10 move­ments during one treatment) with the joint supported using the glide necessary to improve mechanical position or alignment, the motion is generally dramatically improved. This allows the patient to function within the new range and avoid loss of the range gained between treatment sessions.

INDICATIONS AND CONTRAINDICATIONS TO JOINT MOBILIZATION

Joint mobilization is used as a treatment modality when limited mobility is expected to be reversible. Such is often the case with osteoarthritis.⁹ Radiographs are required to determine whether or not there is structural alteration or damage to the joint resulting in limited mobility. If there are structural alterations but the degree of mobility restriction is suspected to be greater than these alterations, joint mobilization is indicated to improve functional mobility.

Another indication for joint mobilization is joint pain. Pain can be reduced by using a gentle force in the pain-free range. This is thought to stimulate afferent mechanoreceptor pathways to the central nervous system, reducing pain. If the dis­order produces pain throughout the range, the mobilization should also be applied through range, also known as a large-amplitude mobilization. However, if pain occurs only at the end of range, then treatment is directed at the end of range with a low-amplitude movement. This low-amplitude movement at the end of range is known as grade IV mobilization and is discussed later in this chapter.⁹

Studies indicate that the use of early mobilization following fracture improves the clinical and functional recovery, resulting in a more rapid and complete return of range of motion and strength.¹³

Contraindications to joint mobilization include joint hypermobility, as in rheumatoid arthritis and other conditions in which the patient does not have active voluntary muscular control for stability, and compromised ligamentous joint sta­bility. Care must be taken when treating patients during pregnancy because of the hormonal effects on ligaments. This is especially the case at the joints of the spine and sacroiliac region. Joint mobilization should also be avoided when a joint is acutely swollen and inflamed.⁹

GRADES OF ARTICULARY MOVEMENT

In order to communicate and document treatment techniques in a concise and simple manner, grades of articulary mobilization have been established. This is especially helpful if more than one therapist is treating the same patient. The grad-

184   Joint Mobilization

ing system used may differ from one school of thought to another, but Maitland’s grading system (below) is commonly used⁹:

Grade I. A small-amplitude movement performed at the beginning of range. This is approximately the first 20% of joint play.

Grade II. A large-amplitude movement performed within the range but not reaching the limit of the range. It is performed between 20% and 60% of the avail­able joint play. If the movement is performed at the beginning of this range, it is expressed as II-, and if it is taken deeply into the range, yet still not reaching the limit, it is expressed as II+.

Grade III. A large-amplitude movement performed up to the limit of the range. This movement can also be expressed with plus and minus values. If the mobiliza­tion knocks vigorously at the end of range, it is graded a III+, but if it nudges gently at the limit of the range it is expressed as III-.

Grade IV. A small-amplitude movement at the limit of the range, well into resist­ance. This can also be expressed as IV+ and IV-, depending on the vigor, using the same criteria described for grade III.

Grade V (joint manipulation). This is a high-velocity, short-amplitude thrust from the limit of range to beyond. This grade of movement will not be explored further in this chapter.

If the normal range of joint movement or joint play is restricted by a joint dis­order, grades III and IV are restricted to the new limit of the range, and grade II movements are restricted to smaller amplitudes. Similarly, in the case of a hyper-mobile joint, these movements are altered.

EXAMINATION

A thorough examination is necessary to determine the source of joint pain and the appropriateness of joint mobilization. Limited joint motion can be present for a variety of reasons. The examiner must avoid assumptions and allow time for good communication with the patient. Connective tissue disorders of the skin and neu-romuscular disorders should be ruled out before assuming that the limitation is due to an articulary disorder. During the exam, the periarticular structures are examined to determine the source of pain. This is done through active and passive range of motion, isometric resistance, traction, compression, and palpation testing. During passive range of motion, the noncontractile tissues are tested. If the pain that was present during active range of motion disappears with passive range of motion, then a reason other than joint dysfunction should be suspected. If pain present during passive range of motion disappears with distraction, articular causes of the pain should be expected. Compression to the joint should again reproduce the pain. When traction or distraction to the joint increases pain, pain most likely is originating in the ligamentous or muscular structures, placed on stretch. A mus­cular origin of pain can be confirmed by applying isometric resistance to the muscle in question. Keep in mind, however, that muscle activity increases joint compression and will increase pain in a painful joint. If the pain is of muscular origin, this can be further confirmed through palpation.

The examination must also include a detailed history including the mechanism of injury, subsequent symptomatology, nature of symptoms, pain description and pat-

Joint Mobilization    185

tern, aggravating and relieving factors, functional loss, and past pertinent medical care. Function is then assessed including active and passive range of motion. The patient’s willingness to move as well as the quality of motion should be determined. Observe any crepitus. Check end-feel and stability. The contractile structures should be tested for pain and weakness. Isometric resisted movements create tension only in the contractile structures, while the “inert” structures remain static. This helps in dif­ferential diagnosis. Strength should be graded using the 0 to normal or 0 to 5 method. Traction and compression can be used to assess the anatomic joints, includ­ing the intra-articular structures, as can gliding or translatory movement.

The examination continues with palpation of the skin, muscle, tendons, bursae, tendon sheaths, joints, nerves, and blood vessels. If necessary, neurologic tests can be included to rule out peripheral and central neurologic involvement. Based on the findings, additional radiography and laboratory tests should be included.

The clinician should then determine if there is a correlation between the objec­tive findings and the complaints of the patient. Do the joints have a normal pain-free range of movement and stability? Could there be other causes of the pain: neu-romuscular, vasogenic, autonomic, psychogenic, or a combination? What treatment can be done? What structures are responsible for the limited joint motion? How does this affect my decision on mobilization techniques available to me? Before a definite diagnosis has been made, a trial treatment may be given. After a few days, based on the results, a positive diagnosis can be made.

In some situations, the use of classic articulary mobilization techniques are not the best choice of treatment to restore range of motion and function to the com­promised joint. When structural changes have taken place in the periarticular structures, such as shortening of the capsule, ligament, or adhesive formation, low-load prolonged stress to the tissues may be more effective. This is administered in the form of CPM, splinting, and active stretching exercise.¹⁰

CASE STUDY

A 35-year-old man sustained a comminuted fracture to the left distal radius as a result of a motorcycle accident. Surgical open reduction with internal fixation was per­formed followed by 6 weeks of immobilization. At 8 weeks, physical therapy was initi­ated. At the onset of care, active and passive range of motion were limed as follows: flexion, 30°; extension, 5°; radial deviation, 5°; ulnar deviation, 15°; supination, 10°; pronation, 60°. The incision sites had healed nicely, but heavy scar tissue was present over the volar aspect of the wrist, contributing to the loss of mobility into flexion and extension. Functionally, the patient complained of difficulty holding objects such as a plate of food due to the limited supination and lack of functional grip strength. He was a meat cutter by trade, and his goal was to return to work without restrictions.

The initial emphasis of physical therapy was placed on restoring range of motion. Because supination was severely restricted, it was decided to augment his home range of motion exercise program with a CPM device to be worn through the night as tolerated and during waking hours wheot actively using the hand. The patient also performed active and active-assisted range of motion exercises, as well as passive stretching into all planes of motion at the wrist, forearm, and hand. This was performed three times a day by the patient independently.

186   Joint Mobilization

Figure 2. Radiocarpal joint: volar glide.

The patient attended physical therapy appointments three times per week over the course of 8 weeks, where the physical therapist performed manual joint mobilization techniques (Figs. 2 and 3). This consisted of stage 3 traction to the radiocarpal joint combined with small-amplitude, staccato mobilization at end-range (grade IV) flexion, extension, ulnar, and radial deviation. Grade IV mobi­lization was also applied to the radioulnar joint both proximally and distally at end range supination and pronation. Similar mobilization forces were applied to the metacarpophalangeal and interphalangeal joints of each finger as well as to the carpometacarpal joint of the thumb with goals of achieving full finger flex­ion and thumb opposition. Finger extension had remained intact so did not require treatment. Following the mobilization directed at restoring joint play, passive sustained stretching was performed to each joint. This entailed a steady

Joint Mobilization    187

sustained hold of the joint at the end of range up to the patient’s pain tolerance. Once pain reduced, additional force was applied gradually to the new end of range and repeated for a total of 3-4 end-range positions, based on the patient’s tolerance. This was directed at the periarticular structures that had shorted over the course of immobilization required following the fracture and surgical reduc­tion or stabilization.

At the end of 8 weeks of treatment, forearm-wrist supination had improved to measure 85°. It was decided to increase efforts to restore wrist extension because this would allow the patient a more functional wrist position to perform the heavy gripping required for his occupation. The CPM device used for the purpose of increasing supination was returned to the vendor and replaced with a dynamic splint (Dynasplint) designed to place continuous low-grade pressure on the wrist into extension, thereby increasing total time spent receiving passive sustained stretch at the periarticular structures that were restricting this motion.

Manual therapy continued as described above, diminishing to two sessions per week as additional exercise was implemented directed at restoring strength to the forearm, wrist, and hand.

After 12 weeks of care, range of motion measures were: flexion, 70°; exten­sion, 50°; radial deviation, 20°; ulnar deviation, 35°; supination, 85°; and prona-tion, 85°. Motion was no longer changing significantly between sessions. The patient was able to return to work as a meat cutter approximately 4 months from the injury. To determine the need for continued care to maintain the gains in mobility and strength, the Dynasplint was discontinued, and the frequency of treatment was reduced from twice per week to once per week, then down to once every 2 weeks, with a final session after 1 month without care for reassess­ment. Range of motion had been maintained by the patient’s active use of the wrist and with his home exercise program. Periodically, the patient would expe­rience bouts of pain accompanied by mild swelling over the tendons at the dorsal and radial aspect of the wrist, especially those tendons responsible for thumb extension and abduction. This was treated with the application of ice and rest because this was always preceded by heavy use of the wrist and hand. Pain and swelling were attributed to inflammation of the tendons not yet accustomed to resistive activity.

The patient was discharged and advised to contact his doctor and physical ther­apist if a loss of function at the wrist and hand developed. Follow-up at 1 year posdnjury found the padent continuing his occupation with near normal use of his wrist and hand.

INDIVIDUAL JOINTS

Each joint must be understood in relation to these criteria for effective and safe treatment. In order to provide effective treatment, the shape of the joint surfaces must be understood, normal joint mobility and the resting and close-pack positions must be known. The shoulder girdle is one of the most complex and most fre­quently encountered peripheral joints. The specifics of the shoulder girdle com­plex are outlined here, but the same type of information must be understood for each peripheral joint requiring treatment (Table I).⁸

188   Joint Mobilization

________ Table 1. Normal Peripheral Joint Positions      

The Fingers: PIP, DIP, and MCP loints

O-Position: The fingers are straight with the long axis through the metacarpal and phalangeal bones Resting position: Slight flexion (approximately 15°) Close-packed position: PIP, DIP, and MCP joints completely flexed Voluntary ranges:

DIP flexion: 90°

PIP flexion: 120°

MCP flexion: 90°, abduction: 45°, adduction: 15° Nonvoluntary ranges:

Traction

Dorsal and volar gliding

Radial and ulnar gliding

MCP also rotation

The Thumb: Carpometacarpal Joint

Voluntary range:

Flexion and extension: 50°

Abduction and adduction: 40°

Circumduction Nonvoluntary range:

Traction

Rotation

Dorsal and volar gliding

Radial and ulnar gliding

The Wrist: Carpal loints of 8 Bones (Pisiform, Triquetrium, Lunate, Scaphoid, Hamate, Capitate, Trapezoid, and Trapezium)

0-Position: The long axis of the radius and the third metacarpal are continuous Resting position: Same as 0-position, but with the wrist in slight flexion Close-pack position: Maximal wrist extension Voluntary ranges:

Flexion: 90°

Extension: 85°

Ulnar deviation: 45°

Radial deviation: 20° Nonvoluntary ranges:

Dorsal and volar gliding

Radial and ulnar gliding

Mobilizing of the individual carpal bones

The Elbow: Humeroulnar and Humeroradial loints

0-Position: Extended elbow

Resting position: 80-90° flexion at the elbow

Close-pack position:

Humeroulnar: Maximum extension and maximum supination

Humeroradial: 90° flexion with the forearm 5 supinated Voluntary range:

Flexion: 135°

Extension: 160-180° Nonvoluntary range:

Separation of the joint surface (traction)

Anterior and posterior glide of the radius

Continued oext page

Joint Mobilization    189

____ Table 1. Normal Peripheral Joint Positions (continued)       

The Forearm: Radioulnar Joints (Distal and Proximal)

0-Position: Elbow flexed 90° to the side of the body and radio-ulnar joint in supination

Resting position: Midway between pronation and supination, elbow flexed

Close-pack position: With the forearm in 5 supination, the interosseus membrane is maximally tightened.

Voluntary range:

Pronation: 75°

Supination: 85° Nonvoluntary range:

Distal radioulnar joint: dorsal and volar gliding

Proximal radioulnar joint: anterior and posterior gliding

The Ankle: Talocrural Joint

0-Position: Right angle between the tibia and the lateral edge of the foot Resting position: Slightly plantar flexed Close-packed position: Maximum dorsiflexion Voluntary range:

Plantar flexion: 25°

Dorsiflexion: 15° Nonvoluntary range:

Anterior and posterior gliding

Separation of the joint surfaces

The Knee Joint

0-Position: The long axis of the femur shaft and the tibia are continuous Resting position: Approximately 45° flexion Close-pack position: Knee maximally extended Voluntary range:

Flexion: 135-150°

Extension: 135-150°

Medial rotation: 10-15°

Lateral rotation: 20-25° Nonvoluntary range:

Anterior and posterior gliding

Traction

Rotation

Distal and proximal glide at the patella

The Hip Joint

0-Position: The trunk and thigh in the same frontal plane. Right angle between a line connecting the

two ASIS of the pelvis, and a line from the ASIS through the mid patella

Resting position: About 45° flexion and 20° abduction

Close-packed position: Maximum extension from 0°, maximum internal rotation, and maximum abduction

Voluntary ranges:

Flexion: 120°

Hyperextension: 10-15°

Medial rotation: 25-35°

Lateral rotation: 40-45°

Abduction: 45-50°

Adduction: 20-30° Nonvoluntary ranges:

Separation of joint surfaces

Rotation

PIP = proximal interphalangeal, DIP = distal interphalangeal, MCP = metacarpophalangeal, ASIS = ante­rior superior iliac spine.

190   Joint Mobilization

Shoulder Girdle

The shoulder girdle comprises four separate functional units: the glenohumeral joint, the scapulothoracic joint, the acromioclavicular joint, and the sternoclavicu-lar joint. The glenohumeral joint is a multiaxial ball and socket joint. The articu­lar surfaces are the glenoid fossa on the scapula and the humeral head. The joint surfaces are reciprocally curved with the convexity of the humerus being much larger than the glenoid cavity. The glenoid cavity is deepened somewhat by the fibrocartilaginous glenoid labrum.

Two of the important ligaments of the glenohumeral joint are the glenohumeral (anterior, middle, and superior), which reinforces the anterior capsule, and the coracohumeral, which helps prevent the humeral head from gliding distally.

Certain tendons strengthen the capsule, most notably those belonging to the rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularis). The capsule is weakest ventrally and caudally, and there tends to be more subluxation in these directions. The capsule is penetrated by the long head of the biceps tendon, and trauma to the tendon in this area often creates a tear in the corre­sponding part of the capsule.

The joint capsule is responsible for supplying stability to the glenohumeral joint where there is a high degree of mobility. The anterior capsule is relaxed in the neu­tral position with the arm dependent at the side, but tightens with external rota­tion, horizontal abduction, and extension. The inferior capsule is redundant, having many folds that can become adhered to each other when the arm is immo­bilized in the neutral position. The inferior capsule tightens on flexion and abduc­tion. The posterior capsule tightens on internal rotation and horizontal adduction. With inactivity, all parts of the capsule may become involved, leading to the common diagnosis of adhesive capsulitis.

•    0-Position. The humerus is parallel to the body, the elbow is flexed to 90°, and
the hand is in a sagittal plane.

•    Resting position. The shoulder is in approximately 70° abduction and 30° flex­
ion. The elbow is flexed, and the forearm is in a position to make a 30-40° angle
with the horizontal plane.

•    Close-pack position. The shoulder is in maximal abduction and external rota­
tion.

•    Voluntary range. Abduction, 120°; adduction, 70°; flexion, 120°; extension, 50°;
internal rotation, 60°; external rotation, 80°.

•    Nonvoluntary range. The head of the humerus can be mobilized in relation to
the glenoid fossa superiorly, inferiorly, anteriorly, and posteriorly, and it also can
be rotated and separated (traction) from the fossa (Figs. 4 and 5).

Scapulothoracic Joint

In addition to the glenohumeral joint, the shoulder girdle relies on the scapu­lothoracic joint for smooth coordinated movement between the thorax and the upper extremity. This is known as scapulohumeral rhythm. During the abduction movement of the arm, for each 15° of arm abduction, 10° of motion occurs at the glenohumeral joint, and 5° of rotation occurs at the scapula upon the thorax. When the arm has been abducted to 90° in relationship to the erect body, this is accom-

Joint Mobilization    191

 

Figure 4. Glenohumeral joint: anterior glide.

plished by 30° rotation at the scapula and 60° of the humerus at the glenohumeral joint, a 2:1 ratio (Fig. 6). These relationships are crucial to understanding shoulder dysfunction and the appropriateness of joint mobilization as a treatment modality.

Acromioclavicular and Sternoclavicular Joints

The acromioclavicular joint functions much the same as a triaxial ball and socket joint; however, it does not have convex-concave articular surfaces. Instead, it has a lax capsule and a disc (usually) that changes shape easily and is mechanically defined as a compound plane gliding joint. Its close-pack position is at 90° abduction.

The sternoclavicular joint also functions around three axes in relation to the manubrium. It should be treated as a saddle joint, but because of its lax capsule and a disc that easily changes shape, it can function around these three axes, much the same as a ball and socket joint. The three axes are:

Figure 6. Scapulohumeral movement with arm elevation.

1.The sagittal axis (through the medial end of the clavicle). The clavicle moves
in a cranial and caudal direction with its convex surface around the sagittal axis.

2.The vertical axis (longitudinal through the body and the manubrium). The
clavicle with its disc moves in an anterior and posterior direction, with its concave
surface around the vertical axis.

3.The longitudinal axis (through the clavicle). The clavicle rotates around its
own longitudinal axis.

REIMBURSEMENT

Joint mobilization is recognized in the Physical Medicine Sections of the Current Procedural Terminology (CPT) manuals as “manual therapy.” The CPT code for manual therapy at this time is 97140 and is paid in increments of 15 minutes. The average reimbursement for this procedure is approximately $20.00 per 15 minutes.

CONCLUSION

Peripheral joint mobilization is a manual skill that practitioners have been study­ing and improving for decades. Many of the materials used as references were pub­lished in the 1950s and 1960s, but they remain the most respected texts on manip­ulation of the extremities used by treating therapists today. This chapter is meant only as an introduction to understanding the mobilization process. For more details on any specific peripheral joint, the reference section will be helpful for fur­ther study. The new therapist must receive manual training in the laboratory from an experienced therapist in order to learn the skills required for safe and effective treatment.⁷ Physical therapists do not currently have access to the diagnostic test­ing required to rule out more serious pathology or other contraindication to joint mobilization. The physical therapist relies on the patient’s physician to perform these screening procedures before referring the patient for PT care. Most patients

receive manual joint mobilization two to three times per week from the treating therapist. This is complemented by an exercise program to be performed several times a day as prescribed by the physical therapist. In particularly resistant cases of capsulitis, joint mobilization is required 4-5 days per week to achieve progress.

 

Features LFC with neurological diseases and NEUROSURGERY.
1. Early appointment of exercise. Involves the use of stored functions and start-ups that are adapted to the altered conditions of neurological, visceral and somatic status.
2. Selective use of exercise for restoration of or compensation for lost functions.
3. Using special exercises on pathogenetic principle in combination with exercise zahalnoukriplyuyuchoyu action.
4. Following the principle of adequacy in continuous zminyuvanosti exercise depending on the capabilities of the patient and the presence of a training effect.

5. Gradual steady expansion mode from the motor position lying to the possibility of unrestricted movement.
The means of gymnastics in diseases of the nervous system is the starting position, massage, special medical gymnastics exercises. Latest share:
a) to enhance muscle strength;
b) for a strictly metered muscle strains;
c) for differentiated stress and relaxing muscles and certain muscles;
d) for the correct reproduction of the locomotor act as a whole (rate, fluency, accuracy of movements);
e) protyataktychni exercises aimed at restoring and improving the coordination of movements;
e) antyspastychni and protyryhidni;
a) and ideomotor reflex;
g) the restoration or the formation of new applications of motor skills (standing, walking, household skills);
c) Passive including manual therapy.

Acute strokes – stroke.

 

 

 

 

 

There are 3 stages of rehabilitation of patients with stroke:
1-th – early recovery (up to 3 months)

2 – late recovery (1 year)

3 rd – residual violations of motor functions.

Degree of motor functions:

1-and – light paresis;

2 – moderate fever;

3 rd – paresis;

4 th – deep paresis;

5 th – plehiya or paralysis.

Mode of physical activity depends on:

1 – the patient;

2 – the period of the disease;

3 – stupernyu violation of motor functions.

Modes of physical activity are:

1. Lying severe (1-3 days).

2. 2nd Advanced beds (3-15 days). 2-B – 16-21 days.

3. Palatniy.

4. Free.

Strict bed rest:

1. Class exercise contraindicated.

2. Patient zabezpeuyut calm medication.

3. Treatment provisions, ie, enter into the patient in position opposite posture Bernice – Man.

These are:

– Reduces spastychnist;

– Prevents the development of contractures;

4. The patient laid on his back, on the side, the situation changed 4-6 times a day for 30 – 60 minutes, depending on the patient, muscle tone paretychnoyi limbs.

Extended bed rest: 2 p / day 3.5

Tasks LFK:

1. Improving the functions of the cardiovascular and respiratory systems, prevent complications from their side.

2. Enhancing intestine motility.

3. Improving the trophic tissue Prevention prolezhniv.

4. Reducing m’yazevoho tone for his improvement.

5. Prevention hemiplehichnyh contractures.

6. Preparing for an active turn-healthy side.

7. Stimulation and recovery of isolated active movements paretychniy ending.

Tools:

1. Treatment provisions on his back side.

 

2. Exercise:

– Breathing exercises;

– Active exercises for small, medium, and later for the large joints of healthy limbs;

3. From 3-6 days – passive exercises for the joints paretychnoyi limbs.

4. Teach Freestyle reference pulses to the synchronous movements of isolated passive forearm extension, bending legs.

Extended bed rest: 2 b / 16-21 days.

Tasks LFK:

1. Strengthening zahalnotonizuyuchoho impact on the patient.

2. Learning relaxation of muscles of healthy limbs.

3. Reduction of muscle tone in paretychnyh limbs.

4. Transfer the patient in a sitting position.

5. Stimulation of active movements in the limbs paretychnyh.

6. Anti-pathological synkineziyam.

7. Preparation of the patient before rising.

8. Restoring function support in the lower extremities.

9. Restoring function self healthy limbs.

Tools:

1. Starting position – are important during passive movements of individual segments of the extremities:

Fingers rozhynayutsya easier if tassel bent.

Forearm – arm if converted.

Supinatsiya forearm will be undermined if the elbow bent.

Disqualification of the hip – more complete in a crouched position.

2. a) classes begin with the first active exercise for healthy limbs, and passive – paralytic.

b) while performing active exercises to use lightweight position using:

– Bed frames;

– Blocks;

– Hamachky to maintain paralytic limbs;

c) exercises performed slowly, smoothly, each movement 4-8 times. First limb is returned to the starting position passively, with the instructor, as well as support. Particular attention is paid to the restoration of movement 1 – the first finger;

d) passively or actively oppose pathological synkineziyam:

– During active leg movements of the hand fixed on the head or along the trunk, buttocks during wreaths;

– When a healthy arm bent, Methodist may at this time passively straighten paretychnu hand;

– Use volitional effort, bending leg patient counteracts bending arms, holding her Freestyle efforts to straighten out the situation;

e) ideomotor movements;

e) isometric muscle tension paretychnoyi limbs.

Palatniy mode.

Tasks LFK:

1. Reducing m’yazevoho tone.

2. Anti hemiplehichnym contracture.

3. Further recovery of active movements.

4. The shift in standing position.

5. Learning to walk.

 

6. Anti synkineziyam.

7. Restoration skills and self-applied domestic movements.

Free profile.

The task means and methods of exercise on the rehabilitation stage and late in the period of residual motor disorders depends on the degree of violations of motor functions:

1 and degree (light paresis)

– Zahalnotonizuyuchyy effects on the body;

– Strengthening the shoulder girdle muscles and back;

– To improve posture;

– Movement of walking.

5-th degree (plehiya, paralysis)

– Revitalization of the cardiovascular and respiratory systems;

– Training the patient to return to the side;

– Preparation to go into a sitting position or standing;

– Improved support function of the lower extremities;

– Relaxing the muscles of healthy limbs;

– Reduction of muscle tone;

– Opposition contracture;

– Violations of trophic paretychnyh limbs;

– Expansion of self-service skills.

Degrees of physical and social adaptation of home patients:

1. Easiest level – the defect is felt only by the patient.

2. Light level – a defect occurs when any purposeful physical activity, visible from the side, not invalidyzuye patient.

3. Intermediate – limited to the major parties independent of physical activity. Requires partial-handed at home and at work – change of career.

4. Heavy power – social and domestic activity of the patient considerably limited. Almost no action except the most basic, is impossible without assistance. Work excluded. The patient fully invalidyzovanyy.

5. Very heavy power – no independent movements and actions possible. The patient always depend on third-party maintenance and support.

LFC in paralysis and paresis.

Paralysis (Greek paralysis) – loss, fever (Greek haresis) – 1) weakening of motor functions in the absence or decrease in muscle strength, 2) violation of the structure and function of motor analyzer, 3) as a result of pathological processes in the nervous system.

Share the following forms of paralysis and paresis:

The nature of damage and violation of the relevant structures of the nervous system:

 Organic :

The result of organic changes in the structure of central-ment and peripheral motor neuron (head, back, brain, peripheral nerve) arising under various Patolo hichnyh processes: trauma, tumors, strokes and other inflammatory processes
 Functional :
Corollary influence of psycho-genetic factors that lead to neyrodyna-мічних disorders in the CNS and meet it head-way to hysteria

Reflector:
 Result neyrody-namichnyh functional disorders them-NS, which arise under the influence of significant fire defeat, topical not associated with paralysis and paresis, which is formed
 
The nature of muscle tone porazhenyh distinguished: the central or spastic, flabby (peripheral) and rigid paralysis and paresises.

Depending on the structural level analyzer defeat motor paralysis and paresises divided into:

  National
(Pyramid) (spastic)

Spasmodic nature of muscle hipertonusu hiperrefleksiya, Pato-logical and protective ref-Lex, abnormal co-friendly movement, no skin reflexes
 

 Peripheral (flabby)

Low (drowsy) muscles. When you defeat peryfe-Hexadecimal motor Heft-Ron
a) atony
b) arefleksiya
infections, infectious-allergic, degenerative strain-som (cell anterior horns of the spinal cord, nuclei of cranial nerves, anterior roots of spinal nerves, brain, spletin, spinal-cerebral nerves or cranial nerves)
 

Ekstapiramidni (rigid)
Rigid muscle tone porazhenyh the violation peel stem-subcortical connections. Characterized by reduction or lack of physical activity. Automatic spivdruzhnih loss-making movements. Drawl, walk small steps with the lack of accompanying movements of the hands. The phenomenon of “gears” with zastyhlistyu
 

 

Objectives gymnastics at the central and peripheral paralysis.

1. Improving blood flow and nerve trophic porazhenyh muscles.

2. Prevention of contractures.

3. Restoration of movement and motor development of compensatory skills.

4. General restorative effect on the patient.

Forms of exercise, their application:

Exercise and massage beginning in the early period of treatment. On the first day laying special paretychnyh extremities. For example, hemiplegia or hemiparesis due to ischemic stroke treatment provisions start from 2-4 days. With Stroke – from 6.8 days (if the patient’s condition allows it to do).

1. Laying on the back of the opposite posture Bernice-Man: shoulder towards allocating at 90 °, elbow and fingers unbent, tassel supinovana, held by the hands lonhetoyu. All finite fixed with the help of sand bags.

2. Paralyzed leg fold in the knee at an angle of 15-20 °. Foot position in the back bending angle 90 °.

 

 

3. Laying on his back on duty with the provisions of the healthy side. Frequency change the provisions of 1.5 – 2 hours.

4. Simultaneously applying massage.

Of course using stroking, rubbing, kneading easy, continuous vibration.

Massage in CB sampling: 1) muscles of hipertonusom stroking massage in a slow pace, and their antagonists stroking, rubbing and kneading at a faster pace, 2) in peripheral (PP): first, stroking the whole limb, and then massage paralyzed m ‘ yazy and their antagonists only slightly pohladzhuyut.

Massages start from the proximal units daily increasing load. In the course of 30-40 sessions of 10-20 minutes. We also show the point and reflex-segmental massage.

5. Along with massage transmitting passive movements in the joints (5-10 movements in each joint in a slow pace).

6. Active gym – is the basic meaning. When CPU for 8-10 days with ischemic stroke and brain haemorrhage – for 15-20 days. You begin to hold limbs in position, then train muscle tone are not enhanced. Exercises using different devices: frame and engine blocks hamachkiv, sloping surface, spring traction apparatus. Then assign active free exercises for patients and limbs.

When PP exercises appropriate to do in the tub with warm water.

7. Teach sit with ischemic stroke (II) within 10 days of onset. When hemorrhage in the brain – in 3-4 weeks.

8. Preparation to start walking in the VP lying and sitting. Teach first standing on two legs, then pocherhvo for sick and healthy, walking on the ground with an instructor in a special wheelchair, using crutches trohopornoyi, on flat surface on the stairs.

Therapeutic exercise in cerebral palsy.

Cerebral palsy (CP) – a brain disease that occurs prenatal, while families in the newborn period or because of various injuries of the nervous system, and violating motor reflex areas, often in violation of the language.

In the course of all forms of CP distinguish 4 periods:

– Sharp – up to 14 days;

– Early recovery – up to 2 months;

– Late recovery – 2 years;

– Residual effects – after 2 years.

In all forms of CP violation are reflex movement iature. Movement possible, but the patient caot manage it.

Voluntary movements, statics associated with controlled alternation of different muscles (contraction, relaxation, stretching). It is essential for the coordinated work of muscles, oporozdatnosti, the formation of a normal scheme and body movements).

Tasks physical therapy:

1. Promote vertical body position of the child, her hand movements and actions.

2. Muscle relaxation in the presence and hipertonusu hiperkineziv.

3. Stimulation of muscle relaxation functions – as a means of preventing the formation of invalid provisions and maintenance of normal motion in the joints.

4. Facilitate the timely development of reflexes that ensure the maintenance of head prysadzhuvannya, seating, standing.

5. Stimulation of the reflex, which is formed on the basis of movement (crawling, perestupannya, walking).

6. Promoting normalization functions vestibular apparatus.

7. Development of hand action.

Planning exercise classes, you must adhere to gradual development of righting reflex and essential skills in accordance with the developmental stages of motor features a healthy child in the first year of life.

Medical gymnastics and massage begins to hold on 2-3 weeks of life.

1. For relaxing muscles recommend pose “embryo” (KA Semenova (1976)): passive bending arms, legs, torso, head of fixed in this position and pokachuvannya. To relax the muscles, you can also teach the child in position on the belly of a large inflatable ball, followed it drifts. Then teach the child to spin the ball, hold massage the abdominal muscles in combination with the diversion of arms, bringing them to the chest and a slight pressing on the chest.
2. To normalize muscle tone and posture correction selectively using point massage.

3. In order to stimulate the reflex crawling with starting position in the abdomen perform deep massage pidoshvynnoyi surface of the left and right foot, then their zahvachuyut transmitting bending and extension legs, causing reflex triple bending. This reflex is a key element of the primary reflex lasagna.
4. Support resistance movements stimulate a step in the upright position with the torso under the arm. Feet rising to 5-6 cm diameter rod that perekochuyetsya under feet.

 

This method causes tension on the extensor resistance legs.

Functional interaction of visual and vestibular analyzers provides orientation in space. They reach maturity in 6 months.

5. In order to normalize the vestibular function is an exercise: lifting the head lying on his back and stomach, parinnya, turns left and right body position to lying on his back, change body position of the child – in trunk tilt side, forward, head down.

6. For most of the visual target exercises should be conducted before a mirror to see your child could movements.

 

7. Exercises to develop articulation, tongue massage.

8. Required orthopedic treatment for a special laying head, hands and feet.

Classes are individual physical therapy, at least 2 times a day lasting 20-30 minutes.

With minor defeat after a year and half can hold group classes for 3-4 children.

LFC ieuritis.
Neuritis – traumatic, infectious, vascular and tonic origin. Needs early active treatment and rehabilitation (depending on the importance of skeletal defects and stage of disease).
LFC in facial nerve neuritis.
Facial nerve neuritis (NLN) shown peripheral paresis or paralysis of muscles mimic the corresponding half of the face, accompanied by its asymmetry.
Impressions to exercise at NLN:
1. Neuritis in infectious and vascular disease.
2. After rapid removal of the tumor and nerve compression.
3. After the complete renovation of acute purulent process in the middle ear, which caused NLN.
4. NLN as a result of surgical intervention on the epitympanitu (rarely).
Tasks gymnastics at NLN:
1. Improved regional blood flow (face, neck).
2. Restoring function mimic muscles.
3. Prevention of contractures and spivdruzhnih movements.
4. Restoration of correct pronunciation.
5. Reduction in serious violations of facial expressions nerve injuries that are not treatable, so that latent defects in the face.
Periods of recovery
Early Primary recovery
In PN 20-40 days 2.12 days 2.3 months
In НХ 30-40 days 3-4 months 2-3 years

Early period.
Using the treatment position, massage, medical gymnastics.
1. Treatment provisions:
– Sleep on the side (on the side of lesion);
– During the day, 3-4 times to sit, tilting his head in the opposite direction, keeping her hand with resistance to the elbow. Thus muscles pull on your good side to side lesion (bottom up) trying to restore the symmetry of the face;

 

– Leykoplasternyy tension with a healthy side of patients with a special helmet-masks;
– Pidv’yazuvannya kerchief;
2. Massage.
Begins with neck neck area. The patient sits in front of a mirror. Masseur to see the full face of all the patient. All massage techniques (stroking, rubbing, light kneading, vibration), a gently, without significant displacement of skin.
Redukatsiya (marking muscles).
3. Medical gymnastics I.
– Dosed tension and relaxation of muscles healthy side (skulovoyi, laughter, the circular muscle of the eye, etc.)
– Napuzhennya and relaxation of muscles that form the images mimic (smile, laughter, attention, grief). These exercises are only a preparatory stage to the main period.
Special exercises to mimic muscles:
1. Raise the eyebrows up.

 

2. Nahmuryty eyebrows.
3. Close your eyes (the stages of exercise: look down, close your eyes, holding eyelid with your fingers on the side of damage, keep your eyes closed for a minute to open and close your eyes 3 times).
4. Smile with closed mouth.

 

5. Schurytysya.
6. Drop the head down, do breath and exhale during the “snort”.
7. Whew.
8. Expand nostrils.
9. Raise the upper lip, upper teeth show.
10. Drop the lower lip, lower teeth show.
11. Smile with your mouth open.

 

12. Redeem lit a match.
13. Dial into your mouth water, close your mouth and rinse, not pouring water.
14. Puffy cheeks.
15. Move the air from one half of the mouth to another.
16. Drop down to the corners of your mouth closed mouth.
17. Eject tongue and make it narrow.
18. Move tongue forward – back with open mouth.

 

19. Move your tongue right – left in the open mouth.
20. Subtract forward lips “tube”.
21. Finger make a circle, followed by his eyes.
22. Involve the cheeks with the mouth closed.
23. Delete upper lip at the bottom.
24. In the closed mouth to drive the tip of the tongue on the gums right-left, pressing the tongue with various efforts.
Major (later) period (II)
Characterized by spontaneous functional recovery of muscles, which is combined with active treatment, special physical exercises and other methods of exercise.
– Fair treatment increased to 4.6 hours (sometimes up to 8-10 hours). Increasing the degree of tension USE reaching hiperkorektsiyi (due pereroztyahnennya and reducing healthy muscle tone. Healthy muscles thus become adversaries of the “allies” the muscles of patients).
– Massage II. A variety of techniques based on the topography of the pathological process. Yes, the muscles that inervuyutsya and branches n. facialis, masazhuyutsya normally. It’s easy and average stroking, friction, vibration of the points. General massage is carried out from the middle of your mouth and do this in a dual role: the regulation of muscle (small) and the actual massage, stimulating blood flow, trophism paretychnyh muscles and others.
Duration 5.11 min massage within 2-3 weeks. In the absence of effect, LH continuing and massage stop at 8 – 10 days. Re-rate – 20 procedures.
– LG III.
LH plays an important role in the rehabilitation period. All the exercises are divided into several groups: 1) the differential stress paretychnyh individual muscles (frontal, nadbrivni, skulovyy, muscle laughter square muscle of the upper lip, triangular chin, mouth circular muscle), 2) dosed tension (relaxation ) all of these muscles with the increasing strength and vice versa, 3) awareness of exclusion from the muscle mimic the different images, situations, smile, laughter, grief, surprise, 4) dosed muscle tension during the pronunciation of sounds. All exercises in front of a mirror with an instructor and independent (2-3 times a day).
Rezydualnyy period (after 3 months).
Same problem: an increase in muscle activity to play a maximum of symmetry between the patients and the parties face (in this period the most frequently occurring contractures mimic muscles)
Therapeutic exercise for spinal osteochondrosis.
The basis of osteochondrosis of the spine is modified intervertebral disc with subsequent involvement in the process of the neighboring vertebral bodies, intervertebral joints and liaison staff.
Mizhhrebtsevi drives play an important role in a stable position of the vertebrae, provide spinal mobility, function as biological absorber.
The factors that contribute to the emergence and development of osteochondrosis is a sedentary lifestyle, prolonged stay in the body physiologically uncomfortable position (several hours sitting at a desk, driving, standing near the machine, behind the counter). This significantly impairs blood circulation and providing nutrients vertebral bodies, intervertebral discs. Having cracked fibrous ring. Due to the progression of degenerative changes in the fibrous ring of fixing broken vertebrae together, there is a pathological level. Mizhhrebtsevi gap decreasing zdavlyuyutsya neurovascular end, blood and lymph vessels – exacerbate pain. In the 3 rd stage of the disease occur gap fibrous ring formed mizhhrebtsevi carpet. The final stage is characterized by thickening and painful vertebral fractures, pathological bone formation rozrostan.
The task of medical gymnastics:
1. Help to increase the distance between the individual segments hrebtsevymy to remove pathological propriotseptyvnoyi impulsatsiyi.
2. To reduce pathological propriotseptyvnoyi impulsatsiyi.
3. Improving metabolism by enhancing blood and lymph in hrebtsevomu damaged segment and spine.
4. Reduce swelling in the tissues placed in charge of an intervertebral foramen, improve blood circulation in the damaged ending.
5. Increase and restore the full amount of movements in the limbs and spine, reducing the static-dynamic disorders and compensatory movements, restoring damaged bearing.
6. Promote the restoration of trophic, tone, muscle strength of trunk and extremities.
7. Increase overall physical capacity.

 

 

Special problems of medical gymnastics:
When radykulyarnomu syndrome:
– Stretching the nerve trunks and roots;
– Prevention of muscle atrofiy;
– Strengthen the muscles distal sections of limbs.
When plechelopatkovomu peryartryti:
– Prevention of formation of reflex neurogenic elbow joint contractures;
– Strengthen the deltoid, nadostnoho, pidostnoho, biceps.
When zadno-cervical sympathetic syndrome (Syndrome of vertebral artery):
– Help to relieve vestibular disorders.

Osteochondrosis of the cervical spine.
Appointed medical gymnastics in the acute period of disease. In classes include exercise for medium and fine muscle groups and joints, muscle relaxation exercises on shoulder girdle and upper extremities. Widely used Primaries movements of upper limbs. They spend a maximum relaxation of shoulder girdle muscles.
After calming down pain therapeutic exercises aimed at strengthening the neck muscles and shoulder girdle. Includes dynamic and static exercises that are alternated with breathing exercises and relaxation of muscles.

 

 

Active movements in the cervical spine in the initial and treatment periods generally contraindicated, because it may cause narrowing of an intervertebral foramen, which cause compression of nerve roots and blood vessels.
Complex 1.
1. VP – Sitting on a chair (kept for the first 7 exercises), lowered his hands along the body. Turn head left and right with the highest possible amplitude. Slow rate. 5-10 times.
2. Drop the head down, chin distayuchy chest. Slow rate. 5-10 times.
3. Polozhyty tassel on his forehead. Bruise on forehead tassel 10 sec rest – 20. Chairman and tassel fixed. 5 times.
4. Polozhyty wreaths at the temple. Squeeze temple at tassel 10 s, 20 s rest. Chairman and tassel fixed. 5 times.
5. This is the other side.

 

6. Hands are omitted along the trunk. Raise the shoulders and hold in this position for 10 s, 15 s relaxation. 6 times.
7. Self-massage of neck, shoulder joints, cucullaris. 5-7 min
8. VP – Lying on his back (saves 8 to 16 right), hands under his head. Squeeze head on hand – out. Relax – breath. Slow rate. 10 times.
9. Hands on a belt. Alternating flexion and extension legs, not reducing the deflection in the waist. Feet from the floor will not tear. 10 times each foot.
10. Hands on waist, legs bent. Prohnutysya, raising the pelvis – exhale, pp – Breath. 10 – 15 times.
11. Bent legs and squeeze into the stomach, obhopyty their hands, head to knees – plays out in. Para – breath. 10-15 times.
12. Hand in hand. Mach, right leg, left hand to touch the right foot. Also the other leg and hand. At 10 times each foot.
13. Hands on a belt. Straight leg raise angle of 90 ° – exhale, lower – breath. 15 times.
14. Hands down. Left leg and arm at the side – breath, pp – Blow. That is another leg and hand. At 10 times each foot.
15. VP – Lying on stomach exercise stick on scoop. Straight legs back-up, head and shoulders raised, prohnutysya. 15 times.
16. VP – Standing navkarachky (stored 16 to 18 drill). Not taking your hands and knees on the floor, to make “round” back – plays out, pp – Breath. 10 times.
17. Vypryamyty right leg – the movement of trunk and back tazom – exhale, pp – Breath. The same left foot. At 10 times each foot.
18. Turn back and head left – breath, pp – Blow. The same right. At 10 times in each direction.
19. VP – Standing on his knees. The left leg pulled aside, VP the same right foot. At 10 times each foot.
20. VP – sitting on the floor, pull the leg in front of another, bending the knees, aside aside. Lean forward to the legs stretched, trying to touch the foot with your hands. Change position of legs. At 10 times in each direction.
21. VP – Standing. Take a seat, heel lifting off the floor, hands forward – plays out, pp – Breath, 15 times.
22. VP – Standing left side to support the left leg straight behind. Right – and exhibited bent forward, body straight. Elastic pokachuvannya. Change position of legs. At 10 times in each position.
23. High on the corners. Gently rotate pan alternately left and right. Do not strain the neck, shoulder girdle and back – the most relaxed body. Vysu Duration – 40 seconds. Repeat several times a day.
24. VP – Standing up, stick in their hands stretched up. Right foot forward – on a stick blade. The same left foot. At 10 times each foot.
25. Stick in their hands stretched up. Stick to the chest, VP Stick to the blades, pp 10 times.
26. Stick to the chest. Tilt forward polozhyty stick on the floor – exhale, pp – Breath. 10 times.
27. Stick in the hands lowered behind (hvat below), tilt forward, hands on the most ardent back up – plays out, pp – Breath. 10 times.
28. Stick in his hands extended in front of chest. Get a stick blow left foot, then right. At 10 times each foot.
29. Mach left foot forward, hands up – breath, pp – Blow. The same right foot. At 10 times each foot.
30. Feet on the width of the shoulders. Tilt forward, touch left foot, right hand, left hand in the way – plays out, pp – Breath. The same with the right foot. At 10 times with each leg.
Complex 2
Each exercise perform 5-6 times.
1. VP – Inverted. Raising the head and shoulders, rotate your body right hands pidtyahnutysya forward-right, the same in the other side.
2. VP – Lying on stomach, hands at sides. Raising the trunk, to withdraw his hands on his head, prohnutysya.

 

 

3. VP – Standing – at the feet shoulder width. Bow to the right, head left circle. The same in the other side.
4. Feet on the width of shoulders, hands on the belt. With a slight slope to the left torso potyahnutysya right hand up, head tilt to the left ear trying to touch the shoulder. The same in the other side.
5. Feet on the width of the shoulders. Circle shoulders back, connecting the blades napivprysid, tilt your head back; pp, round wheel, napivprysid, tilt your head forward.
6. Feet on the width of shoulders, hands on the belt. Climbing up on socks, tilt your head forward, descending on the entire foot, napivprysid head tilt to the right. The same tilting his head left, then back.
7. Feet on the width of shoulders, hands up. Right hand forward, swing aside. The same second hand.
8. Feet on the width of shoulders, hands on shoulders. Raise the shoulders and shoulders forward, then drop down; Rectifier hands up, two spring Mahi handed back.
9. Feet on the width of shoulders, hand in hand. In turn the body right – shresni movements with his hands, back in pp, max hand in hand. The same the other way.
10. Feet on the width of shoulders, hands on the belt. Two spring body bends left, tilt right, vypryamlyayuchys up the socks and go back to the VP The same the other way.
11. Feet on the width of the shoulders, arms behind his head. Semicircle trunk left, tilt right, forward, left. Movement perform smoothly. The same in the other side.
12. VP – Lying on his back, arms along the trunk. Knees bent legs toward your chest, vypryamyty up, then forward the floor.
13. VP – Lying on stomach, arms bent under the chin. Mach right leg up. Same other leg.
14. VP – Lying on his back, arms along the trunk. Sit down, raising his hands up, two spring Mahi hands back, bending the legs obhopyty their hands round the back, tilt his head to his knees.
15. VP – Sitting with support on hand from behind, bent legs apart. Knee right foot drop to the floor to the left. Same other leg.
16. VP – Sitting, legs apart, hands at sides. Turning the trunk to the right, lean to the floor, leaning on the bent arms. The same the other way.
17. VP – Standing on her knees, hands omitted. Derived forward right foot, heel to sit on the left foot, tilt your torso forward, hands to feet potyahnutysya. Two spring bends forward. The same with the other leg.
18. VP – Standing on her knees with support on hand. Descending on the forearm of the left hand, rotate the torso to the right to withdraw the right hand side. The same the other way.
19. VP – Standing. Mach bent right leg forward with left leg napivpysidom to withdraw back to the right toe, hands up. The same with the other leg.
20. Legs wide apart. Nahylyayuchys forward, hands on floor. Bending the right leg towards the knee, heel raise, complementing prysid. The same with the other leg.
21. Feet apart, hands on the belt. Climbing up on toe, heel turn right and drop them on the floor. The same is relying on the heel and turning the socks.

Osteochondrosis of the thoracic spine.
As a result, dystofichnyh degenerative changes in intervertebral discs in the thoracic spine may be flattening or enhancing breast scaliosis. These changes, along with a pain syndrome, lower respiratory excursion of chest, leading to hipotrofiyi respiratory muscles, is violation of lung function.
When sploscheni breast scaliosis to strengthen the muscles of the abdominal wall and stretch long muscles. For this purpose, using physical exercises aimed at

Fig. 15 – Exercises to develop muscles

stretching the spine and strengthening scaliosis.
With increasing breast scaliosis therapeutic exercises designed to strengthen muscles, stretch long muscles and muscles of typhoid press. In class exercises are used to extension of the spine and the thoracic exercises with erection of blades. To achieve a greater effect on gymnastic exercises include objects (Fig. 15, 16).

 

 

Fig. 16 – Exercises to develop flexibility of the spine (complex 4) and upper shoulder girdle (complex 5).

Osteochondrosis of the lumbar spine.
During the exacerbation of the disease patients preferably lie on the solid bed. For relaxing muscles in the knee lay cotton-gauze cylinders. For decompression of nerve roots, improve blood supply appoint traktsiyne treatment. Calm damaged spine creates conditions for scarring cracks and gaps fibrous ring.

 

 

Therapeutic exercises to reduce pain, relax muscles, trunk and extremities, improving blood supply to the nerve roots. In the classes include exercises for units distal lower extremities combined with static and dynamic breathing exercises, relaxation of muscles of trunk and limbs, which carry the original position lying on his back, the abdomen, on the side.

 

 

After calming down of pain is an exercise to “pull” the spine, it “kifozuvannya, to improve blood supply to the damaged section of the spine and surrounding tissues. Exercises performed with a starting position lying on his back, stomach, side, standing navkarachky. Perform movements in the knee and hip joints, spinal flexion exercises and the “pull” on the axis. You perform the exercises with isometric muscle tension: natyskuvaty lumbar area on a couch with legs bent at the knees,

 

 

exercise can complicate one’s buttocks while the muscles and perineum. These exercises increase vnutricherevnyy pressure that leads to a reduction vnutridyskovoho pressure.

 

 

If hipotrofiyi muscles and typhoid press them to strengthen, to form a “muscular corset” that will assist in unloading the spine and in the performance of basic statistical and biomechanical functions.

 

 

When you start calming down the pain centers perform exercises 6, 7, 8 (Fig. 17, 18).
To normalize tone muscles and improve blood circulation paravertebralnyh tissue massage to hold back and lumbar muscles. When radicular syndrome masuyetsya and damaged limbs.
Complex 6
 

Fig. 17 – Exercises for muscles of waist and typhoid press.

 

Fig. 18 – Exercises for flexibility of the spine.

Complex 8
Each exercise perform 5-6 times.
1. VP – Lying on his back, arms along the body, long socks and one’s whole body, potyahnutysya. Relax. The same tightening the socks themselves.
2. Legs bent, one hand along the trunk, the other – up. Potyahnutysya one hand forward, uphill second. Change position of hands.
3. Legs bent, arms along the trunk. Turn head left, hands over the head. Raising his head, tilt her hands to the chest, elbows forward.
4. Hands along the trunk. Bending one leg to tighten its hand to the chest, that is, bending the other leg, lift head and shoulders, trying to touch the forehead to the knees.
5. VP – Standing. Tilt head right semicircle head forward, tilt the head to the left half-round head back.
6. Hands on a belt. Raise one arm, lower. Raise second shoulder – reduce. Raise and lower both shoulders.
7. From pivprysyadom draw hands forward, wreaths themselves, potyahnutysya shoulders and palms forward, with pivprysyadom withdraw hands back without affecting the provisions of wreaths, blades connect.
8. Feet apart, hands at sides. Hands forward – cross, embrace yourself for the shoulders. From pivprysyadom bend hands over his head, trying to finger obhopyty elbow.
9. Feet apart, hands at sides. 8 circular movements of the hands back a small amplitude, wreaths themselves; 8 circular movements of the hands forward, fingers down wreaths omitted.
10. Feet apart, hands at sides. Horizontal tilt forward, arms forward, hands on head, shoulder blades connect, with pivprysyadom trunk inclination towards, potyahnutysya elbow to knee. Same with a slope in the other direction.
11. Tilt body forward, hands on knees; pivprysyad, without changing body position, increasing slope, vypryamyty feet potyahnutysya hands down.
12. Feet apart, hands before breastfeeding. From pivprysyadom turn right torso, right leg back to withdraw. The same the other way.
13. Feet apart, hands on the belt. Revert to the right pelvis, keeping the situation shoulders, legs do not bend. Repeat left. The same starting movement in the other direction.
14. Legs wide apart, hands at sides. 3 spring bends forward, hands potyahnutysya to the floor, arms behind his head, reinforcing the slope.
15. Legs wide apart. Bend one leg, the knee obpertysya hands, tilt your torso forward, bending the same the other leg.
16. Step right foot to side, bending her body tilt to the left hand up, prystavlyayuchy right leg. The same the other side.
17. Lunge right leg forward, back straight, hands on knee, hands up, potyahnutysya back, increasing prysid, repeat. The same with the other leg.
18. Legs apart. Rise to toe, hands up, with pivprysyadom lift bent leg forward, hands obhopyty knee. Same other leg.
19. Hand in hand. From pivprysyadom the left swing right foot to side. Cotton hands over his head. Repeat with other leg. The same vidvodyachy step back.
20. Feet apart, hands on the belt. Climb the socks, roll on the heel, raising their socks up. Deep prysid, hands down.

Fundamentals of manual therapy in spinal diseases,
classification methods.

Manual therapy oformylas independently direction and implemented in the practice of medical institutions. Scientific foundations of manual therapy include:
– Selection in the clinical picture of spinal osteochondrosis and arthrosis of the joints of extremities patobiomehanichnyh acts as a local functional unit, local hipermobilnosti, miodystonichno-miodystofichnyh changes Regionals postural muscle imbalances, motor neoptymalnoho osteotytu;
– Understanding of the spine together with its structures inervuyuchymy central and peripheral organization of the circulatory system as a functional biological system to fulfill its functions through bilateral reflex vertebromotornym, vertebrosensornym, vertebro-visceral and other communications;
– Selected spinal motor segment, which includes two adjacent vertebrae and connecting them to disc, joints, muscles and inervatsiynym software as functional and structural elements of the spine, through which all its functions and pathological changes which are implemented in osteochondrosis;
– Understanding of the reflex mechanism functional unit in a spinal locomotor miofiksatsiyi syhmentu or joint when shifting or jamming parts pulpoznoho nucleus of an intervertebral disc;
– Developed a special technique mainly manual diagnosis motion of joints of the spine and extremities with the aid of passive movements and displacements in them;
– Developed a method of manual therapy, which includes special effects techniques manual that aims to eliminate patobiomehanichnyh manifestations and restore normal motion in the musculoskeletal and locomotor adjustment stereotype.
Indications for manipulation.
1. Pain syndrome in spinal osteochondrosis and stage (dyskalhiya, lumbago, lumbalgia, torakalhiya, tservikalhiya when developing a functional block segment of the spinal reflex.
2. Pain syndrome in the second – the third stage of osteoarthritis, which is characterized by a slight displacement of the vertebrae, mainly in the cervical part, psevdospondylolistezamy, bending fibrous ring of an intervertebral disc, submoksatsiyeyu “the development of various neurological syndromes, including reflex and muscle spasm, trophic disorders in bradytrofnyh tkaknynah: plecholopatkovyy parasynovitis, epikondylit shoulder styloyidyt, hip joint and knee parasynovitis.
3. Pain syndrome, as a consequence of widespread osteoarthritis (I – stage III) considering the priority segment lesions.
4. Autonomic visceral violation, depending on the level of degenerative spine-dystofichnoho lesions: Syndrome of vertebral artery, which manifested vertebrobazylyarnoyu deficiency syndrome Melyera, functional impairment, hearing loss, cardiovascular system (psevdostenokardiya), biliary tract dyskinesia in the absence of organic lesions of the corresponding body .
Relative indications.
1. Pain syndrome in the presence of clearly expressed involyutyvnyh dystofichnyh-degenerative changes in old age, not accompanied by osteochondrosis and zakostenilistyu front longitudinal relationships.
2. Slipped disk.
3. Acute pain on a background of long-term disease (1 month or more).
Contraindications to manual therapy.
1. Congenital abnormalities of the spinal segment, including Atlanta (S 1) and axial vertebra (C 2).
2. Congenital systemic diseases of the spine, accompanied by osteochondrosis (spondyloepifizarna dyplaziya, brittle bones)
3. Excessive mobility of the spinal segment.
4. Vascular violation of the circulatory system of the spinal cord.
5. Massive zakostenilist front longitudinal relationship (spondylosis, Article III) combined with osteochondrosis related departments.
6. Spondyloliz and spondilolistez II – III degree.
7. Spinal osteoporosis of different etiology.
8. Heavy diseases of internal organs.
9. Brain lesion.
10. Inflammatory processes in the spine (tuberculosis, osteomyelitis).
11. Tumors of the spine and soft tissues.
12. Condition after surgeries on the spine and spinal cord.
13. Traumatic injuries of the spine.
Classification techniques of manual therapy.
A. By type of reception methods:
– Mobilization – passive movement, traction, stamping, postizometrychna relaxation, automobilizatsiya;

 

 

– Manipulation – push, push traktsiynyy;

 

 

– Combined techniques.
B. By object of:
– Joints;

 

 

– Muscle.
V. The nature of action:
– Netsilespryamovana (polisehmentarna);

 

– Focused (monosehmentarna) – Contacts, Occlusion, combined (with protytrymannyam, support).
By G. direction:
– Unidirectional (inflection, ekstenziya, laterofleksiya, rotation, adduktsiya, abduktsiya);
– Combined (inflection + + laterofleksiya rotation, and other combinations).