Extremity Biomechanics and Functional Assessment

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Extremity Biomechanics and Functional Assessment

• PRA 635
• Special Thanks to Dr. Corey Campbell!!!

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The Keys to The Castle
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Gold Standard of Manual Medicine

• Manipulation
• Rehabilitation
• Advice
• Soft Tissue / Muscle work

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Soft tissue ART Graston
Neuro- Dynamics (Butler)
Muscle Energy (Lewitt)
Dynamic Stabilization (Kolar)
Motion Palpation Adjusting
McKenzie (MDT)
Functional Rehab (Gary Gray)
Spine-sparing Spine Rehab (McGill)
BPS (Linton, Leibensen, Waddell)
Nutrition (Seaman)
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Moving Forward

• It is the reliance on science and evidence-based
  practice that so distinguishes the manual therapy
  of today from that of the mid-20th century L.
  Twomey

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Blending Art with Science
Manipulate
Reactivate

• We must first teach the patient to avoid that
  which harms them (Karel Lewitt)

Educate
Patient Colleague Confidence
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Palpation...Art within the Science

• Palpation is the hard partapplying the correct
  adjustment from there is easy
• Are you a neuro-musculoskeletal expert?
• What separates you from everyone else?

Hx, Ortho, Imaging
Fxnal Tests, Palpation (jt, mm, nerve)
Roadmap/ Working DX
Patient Tx
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RESTRICTION OF MOTION OF ONE PART OF THE SPINE
CAUSES INCREASED MOTION OF ANOTHER PART OF THE
SPINE (Nordin, Frankel, 1989)

• THE SEGMENTS THAT SHOW THE MOST DEGENERATION
  ARE AT THE PLACES OF THE SPINE WHERE THE MOST
  MOVEMENT OCCURS (Sahrmann, 2002)THE PROBLEM
  WITH MOTION ANALYSIS IS THAT PEOPLE WILL NOT TAKE
  THE TIME TO GET GOOD AT IT (Lewit, 1999)

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Dispelling Myths

• We move bones.
• NO!! 6 degrees of motion, freeing joint movement
  along specific axis, pain inhibition
• Once you are treated you have to keep going back.
• The treatment plan/addressing the underlying
  dysfunction/active
• We dont play well with others.
• The value of a multi-disciplinary
  approach/limitations of conservative care

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Control System CNS
Passive System Joints Bones Ligaments
Active System Muscles
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Centric Relation (Kolar)

• Airplane!

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Functional Manual Care

• Gathering information with our eyes and observing
  movement impairments (Janda, Sahrmann, OConnor)
• Gathering information with joint motion palpation
  (Mennel, Lewit, Illi, Kaltenborne,Gillet, Faye,
  etc)
• A perfect marriage
• Primary dysfunctions will show up in both
  assessments and guide the clinician on key areas
  for treatment

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The Control Subsystem

• What causes the control system to malfunction?
• Injury, poor posture, poor nutrition, stress,
  development
• Loss of control results in
• Faulty motor patterning (effect on articular
  cartilage)
• Failed motor control (joint motion control)
• Release of inflammatory mediators? Pain

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The Control Subsystem

• Alteration in compression strategies is a key in
  neuromuscular dysfunction and pain(Vleeming
  2002)
• Can joints SHARE the movement?
• Joints can
• Move too much (laxity, instability)
• Move too little (restriction)
• Move too much in one plane and not enough in
  another (directional instability)

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Rigidity vs. Control
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Rigidity vs. Control
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Rigidity vs. Control
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Rigidity vs. Control
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Rigidity vs. Control
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Movement Behavior Choices for Stabilization
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Cost of Excessive Compression
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Movement Behavior Choices for Stabilization
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Stress Pattern
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Motor Control
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Concepts Adjustment

• Palpation adjusting are psychomotor skills
• Examples of psychomotor skills are a great golf
  swing, a basketball shot, etc.
• All require knowledge of the activity and then
  practice with intention
• Levels of Competence
• A Unconsciously Incompetent
• B Consciously Incompetent
• C Consciously Competent
• D Unconsciously Competent

Based on Motor Plasticity which is a function of
the neurological changes within the cerebellum
Concise text of Neuroscience Kingsley
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Joint Dysfunction

• A loss of joint play movement that cannot be
  restored by the action of voluntary muscle
• Mennel J. The Musculoskeletal System
  Differential Diagnosis from Symptoms and Physical
  Signs. 1992.

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Joint Play

• Assess both sides (mirror image)
• Small amount of motion (less ?)
• Occurs in a small but precise range
• Joint play allows EASY, PAINLESS, VOLUNTARY
  MOVEMENT

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Joint Signs

• Pain
• Local muscle tension
• Joint restriction
• Mennel, DeFranca G.

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Therapeutic Joint Play

• Accurate diagnosis of joint dysfunction is a
  pre-requisite for therapeutic manipulation. The
  restoration of joint play through manipulation
  results in restoring anatomic and physiologic
  synovial joint function. Treatment is
  accomplished by quickness with accuracy, less
  than an 1/8 in the plane of the joint.
• Mennel J.

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Basic Rules of Joint Play

• Patient must be relaxed
• Examiner must be relaxed
• Examine one joint at a time
• Evaluate one movement at the joint at a time
• One mobilizing force and one stabilizing force
• Mirror image comparison
• Dont force abnormal movement
• Stop if pain is elicited
• No examination if joint/bone inflammation or
  disease is suspected
• Mennel J.

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Joints of the Shoulder Complex
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Superior View of Both Shoulders in the Anatomic
Position

• Angle A Orientation of clavicle deviated about
  20 degrees posterior to frontal plane
• Angle B Orientation of scapula (scapular plane)
  deviated about 35 degrees anterior to frontal
  plane
• Angle C Retroversion of humeral head about 30
  degrees posterior to medial-lateral axis at elbow

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Glenoid Fossa Tilt

• Approximate 5 upward tilt of the glenoid fossa
  relative to the medial border of the scapula

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Angle of Inclination b/w Shaft and Head of
Humerus and Retroversion
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Upper-Crossed Syndrome
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Lower-Crossed Syndrome
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Shoulder Abduction
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Faulty Shoulder Abduction
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Push-Up Test
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Faulty Push-Up Test
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Motions of Scapula Against Surface of Thorax
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Sternoclavicular Joints
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Anterior-lateral View of Sternoclavicular Joint
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Osteokinematic Motions of the Clavicle
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Arthrokinematics Clavicle During Elevation and
Depression About the Sternoclavicular Joint

• (Costoclavicular ligament CCL, superior capsule
  SC,
• interclavicular ligament ICL)

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Arthrokinematics of Clavicle During Retraction
About the Sternoclavicular Joint

• (Costoclavicular ligament CCL, anterior
  capsular
• Ligament ACL, posterior capsular ligaments
  PCL)

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Acromioclavicular Joint
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AC Joint Including Surrounding Ligaments
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Shoulder Striking Ground with Force Directed at
Acromion
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Osteokinematics of AC Joint
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Scapulothoracic Elevation Elevation at SC and
Downward Rotation at AC Joints
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Scapulothoracic Protraction Protraction at SC
and Slight Horizontal Plane Adjustments at AC
joints
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Scapulothoracic Upward Rotation Elevation of
the SC and Upward Rotation at AC Joints