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Best Augmented Home Exercise Programs APTA/AAOMPT
Summary of Evidence Best Augmented Home Exercise Programs g Chad Cook PT, PhD, MBA, OCS, FAAOMPT Professor and Chair Walsh University Phllip Sizer Jr, PT, PhD, OCS, FAAOMPT Professor and Program Director Texas Tech University Health Science Center Cook C. Orthopedic manual therapy. Upper Saddle River; Prentice Hall: 2007. APTA/AAOMPT Definition • “Manual therapy techniques consist of a broad group of passive interventions in which physical therapists use their hands to administer skilled movements designed to modulate pain; increase joint range of motion; reduce or eliminate soft tissue swelling; inflammation; or restriction; induce relaxation; improve contractile and noncontractile tissue extensibility; and improve pulmonary function. These interventions involve a variety of techniques, such as the application of graded forces.” Guide to Physical Therapist Practice. Revised 2nd ed. Alexandria, Va: American Physical Therapy Association; 2003. Categorization Temporal Effects (Thrust Manipulation) • Short-term effects only (30 minutes to 5 hours) • “The temporal pain-relieving benefits following HVLAT in subjects with spinal pain are immediate and short-term in nature and demonstrate little to no carry-over when applied alone. While clinical changes in pain and function are frequently noted when these techniques are used, it is possible the carry-over benefits may be attributed to another factor or the interaction of HVLAT and some activity or exercise program, more so than the exclusive benefits of HVLAT” Coronado RA; Bialosky JE; Cook CE. Physical Therapy Reviews, 2010; 15 (1): 29-35 Temporal Effects (Non-Thrust Manipulation) • Short-term effects only (1 to 5 minutes) • May require augmentation for carry-over effects • There Th are short-term h tt benefits b fit for f pain i and d estimate of beneficial global effect with both mob and sham mob (incorrect technique or level) Bialosky et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Man Ther. 2008;1-8. Slaven E, Coronado R, Hegedus E. J Man Manip Ther. 2011;19: 1 Effects of Manual Therapy Don’t Last Long Is it this? Or can we be better if we are more specific? • Immediate effects have been reported with superficial heat, long-wave ultrasound, short-wave diathermy, and specific exercises. • In addition, immediate effects have been identified using massage , kinesiotaping , passive physiological movements, acupressure, ischemic compression, thermal ultrasound, simple touch, ice massage and strain-counterstrain. • Even more notable and dubious are the immediate effects findings of improved active mouth opening after hamstring stretching, improved hamstring mobility after suboccipital stretching, and improved spatial cognitive tasking after breathing through the left nostril only. How does Augmentation Work? • Biomechanical • Neurophysiological • Psychological y g Cook C. Immediate Effects from Manual Therapy: Much Ado about Nothing? J Man Manip Ther. 19(1). 2011. Augmented Home Exercise Program? • A defined, specific home program, unique to each patient, that facilitates the desired movements that address either the impairments of the patient patient, reduce pain and/or centralize symptoms, or move into the direction of the manual therapy technique applied, performed exclusively by the patient. Biomechanical Changes with OMT • Biomechanical (Improvement in impairment associated with movement) • Such as: – Vertebral position – Range of motion – Pliability of the joint • Short term only versus controls (Gal et al. 1977; Mierau et al. 1988) 2 Neurophysiological Changes Does Augmentation Work? • Spinal Cord Hypoalgesia (Diminished sensitivity to pain) • Sympathoexcitatory (changes in blood flow, heart rate, skin conductance, and skin temperature) • Lessening of Temporal Summation (CNS condition, which demonstrates an increase perception of pain to repetitive painful stimuli) • Peripheral Inflammatory Mediators (Alteration of blood levels of inflammatory mediators) • Central Mediated (Alterations in pain “experience” in the ACC, amygdala, periaquaductal grey, and rostral ventromedial medulla) • Muscle Reflexogenic (decrease in hypertonicity of muscles) Bialosky et al. The mechanisms of manual therapy in the treatment of musculoSkeletal pain. A comprehensive model. Man Ther. 2008;1-8. Neurophysiological Changes with OMT It’s a bit Do you get it?? Evidence to Support Augmented Manual Therapy? Psychological Changes So what happens with Augmented Exercise? complicated… • Placebo (active approach versus nothing) • Improvements in depression, mental component scores (not fear avoidance scores) • Expectancy Williams et al. Psychological response in spinal manipulation (PRISM). J Comple Ther Med. 2007;15:271-283. Bialosky JE et al. The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects. BMC Musculoskelet Disord. 2008 Feb 11;9:19. • We Don’t Know! • What might we suspect? – – – – Tissue response Biomechanical response p Sensorimotor learning Æ control response Biopsychosocial response • Bottom Line? NO DIRECT EVIDENCE 3 The Sackett ‘Solution’ SR’s MA’s Mult RCTs 4 Problems • Based on rigor vs. relevance • Universal Conclusions -MA’s & SR’s • Statistical vs. Clinical Confidence • The Changes in ‘Science’ RCTs Case Control Studies, Lg Case Series Case Reports, Sm Case Series Unsystematic Clinical Observation No Direct Evidence? What about Sensorimotor Control & Learning? Evidence ‘Informed’ Practice Clinical Observation, & Expertise Case Reports, Sm Case Series Case Control Studies, Lg Case Series RCTs Mult RCTs SR’s MA’s No Direct Evidence? Evidence for: Trust YOUR Judgment! • Engage a sensorimotor learning process • Activate both the locomotor (feedforward) AND somatosensory (feedback) mechanisms • Exercise Prescription • Engages the Stages (of learning) • Platform for continued movement (Practice effect) Schmidt RA, Lee T. Motor Control and Learning - 4th : A Behavioral Emphasis. Human Kinetics, 2005 Tangential Evidence to Support an Augmented Home Program • Should be specific, supervised, and adherent. It’s more important outside of PT than during. • If you can create a behavioral change that lasts beyond y formal care, then the outcome is more powerful than ANYTHING done in formal care. Hayden et al. Systematic review: strategies for using exercise therapy to improve outcomes for LBP. Ann Intern Med. 2005;142:776-85.. Maul et al. Long-term effects of supervised physical training in secondary prevention of low back pain. Euro Spine J 2005; 14:599-611. Mannion et al. Spinal segmental stabilisation exercises for chronic low back pain: programme adherence and its influence on clinical outcome. Eur Spine J. 2009;18:1881-91. SensoriMotor Learning Processes Processes are associated with practice or experience leading to inferred, relatively permanent changes in the capability for movement Target Æ Skilled action Platform Æ practice or experience Assessment Æ Results of Learning Duration Æ relatively permanent changes in the capability for skilled behaviors Schmidt RA, Lee T. Motor Control and Learning - 4th : A Behavioral Emphasis. Human Kinetics, 2005 4 Neuromuscular Control “Unconcious efferent response to an afferent signal concerning joint control” Preparatory ((anticipatory) p y) Feedforward control (FF) Previous experience Integrated with ongoing information Reactive (reflexive) • Feedback control (FB) • Constant adjustment • Posture and “slow” movement Lephart SM, Riemann BL, Fu FH. Introduction to the sensorimotor system. In: Lephart SM & Fu F, eds. Proprioception and Neuromuscular Control in Joint Stability. Champaign, IL: Human Kinetics; 2000. Developmental: How are Movements Learned? Stages of SensoriMotor Learning • Cognitive • Associative • Autonomous Schmidt RA, Lee T. Motor Control and Learning - 4th : A Behavioral Emphasis. Human Kinetics, 2005 Reminder How do we build an EvidenceInformed Program? Practice Decisions • Factor 1: Volume of Practice! • Factor 2: Variability in Practice! • Factor 3: Part vs. Whole Practice • Factor 4: Sufficient Recovery! y • Factor 5: Appropriate FB, Guidance, & Modeling • Remember: Performance ≠ Learning Schmidt RA, Lee T. Motor Control and Learning - 4th : A Behavioral Emphasis. Human Kinetics, 2005 Rules of Thumb for Augmented Exercise Prescription • Consider Direction (Opening versus Closing, etc.) • Consider Hydration • Consider C id A Activation ti ti – Functional Arthrokinematics – Stretch – Movement Pattern Support – General Activation – Psychological Support The Foundation “As to the methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.” Ralph Waldo Emerson 5 Cervical Lower Cervical (Augmented Functional Glides) C2C3 Extension Glide Upper Cervical (Cervico-Ocular Augmented) • 3-D Sidenods in Protraction / Retraction • 3-D Rotations in Protraction / Retraction Lower Cervical • • • • 3-D Rotation in Extension (Cervico-Ocular Augmented) 3-D Rotation in Flexion (Cervico-Ocular Augmented) Self-Side Scoop Self-Dorsal/Ventral Upper Cervical Lower Cervical (Augmented Functional Glides) (Augmented Functional Glides) • C0C1 DorsalGlide (R) C6C7 Flexion Glide (R) What about C1C2? Move hands down 1 segment and use rotation Demonstrate Movement Pattern Reinforcement for C0C1, C1C2 Upper Cervical Lower Cervical (Augmented Functional Glides) (Augmented Functional Glides) • C0C1 Ventral Glide (R) • C3C4 Lateral Glide (Scooping) What about C1C2? Move hands down 1 segment and use rotation Demonstrate Movement Pattern Reinforcement for C0C1, C1C2 6 Lower Cervical (Hydration Management; Movement Pattern Reinforcement) Prayer Stretch • C5C6 Dorsal Ventral Glide (Jenkner) Thoracic • • • • • • • Foam Roll Sitting Extension (Grieve Stretch) Prayer Stretch Foam Roll Wall Stretch Wall Angel Supine Resisted Movement Upper Thoracic Extension Stretch Sitting Extension Wall Angel 7 Upper Thoracic Extension Stretch Shoulder Glenohumeral: • GHJ Flex + Caudal Glide Augmented Functional Glide Glenohumeral: • GHJ Passive IR Stretch in ADduction Glenohumeral Functional Arthrokinematic • GHJ Abduction + Caudal Glide • GHJ Abduction in ER + Caudal Glide • GHJ Flexion + Caudal Glide UE End Range Elevation • Elevation + Dorsal Glide • Elevation + Caudal Glide • Elevation + Ventral Glide Glenohumeral: • GHJ Passive IR Stretch in ABduction Glenohumeral: GHJ Abd + Caudal Glide Augmented Functional Glide 8 UE End Range Elevation • Elevation + Dorsal Glide Augmented Functional Glide Elbow Humero-Ulnar Joint • Neuromuscular Re-Education • Self Glides in Flexion and Extension Humero-Radial Joint • Neuromuscular Re-Education • Self Glides in Flexion and Extension Proximal Radio-Ulnar Joint • Neuromuscular Re-Education • Self Glides in Flexion and Extension UE End Range Elevation • Elevation + Ventral Glide Augmented Functional Glide UE End Range Elevation • Elevation + Caudal Glide Augmented Functional Glide Humero-Ulnar Joint • Self Glides in Extension Augmented Functional Glide Humero-Ulnar Joint • Self Glides in Extension Augmented Functional Glide 9 Proximal Radio-Ulnar Joint Coupling Movements • Self Glides in Pronation Augmented Functional Glide What About Supination? Humeral-Radial Joint Self Mobilization: Ulnar Glide • Self Glides in Extension Augmented Functional Glide Wrist-Hand • Coupling close chained mobilization for extension and radial deviation • Coupling open chained mobilization for flexion and ulnar deviation • Self mobilization ulnar glide during extension Lumbopelvic • • • • • Extension with Adjustments Self side glide Hurdler’s stretch Kneeling flexion Standing lunge 10 Extension with Adjustments Kneeling Flexion Self Side Glide Standing Lunge Hurdler’s Stretch Hip • All 4’s with IR/ER and posterior glide (rocking) • Military crawl position • Piriformis Pi if i stretch t t h 11 All 4’s Lateral Capsule Knee Patellofemoral • Lateral Retinacular self stretch • Augmented Functional Glides Tibiofemoral Complex • Tibiofemoral functional glides • Meniscofemoral functional glides • Meniscotibial functional glides Military Crawl Position Patellofemoral (Lateral Retinaculum): Piriformis and Lateral Capsule Patellofemoral (Lateral Retinaculum): • Patellar medial glide self stretch • Patellar medial tilt self stretch 12 Patellofemoral: Augmented Functional Glides • Medial Patellar Glide / Tilt with Terminal Ext Tibiofemoral Complex Functional Glide • Meniscofemoral Anterior-Distal Glide in CKC Extension Motion Patellofemoral: Augmented Functional Glides • Medial Patellar Glide / Tilt with Flexion Tibiofemoral Complex Functional Glide • Meniscotibial Anterior Meniscal Glide in CKC Extension Motion RESISTANCE Tibiofemoral Complex Functional Glide • Tibiofemoral Anterior Glide in CKC Extension Motion Ankle Foot • Talocrural Complex – Functional Glides • Subtalar Complex – Movement M t Pattern P tt Reinforcement R i f t – Functional Glides • Midtarsal Complex RESISTANCE – Self Stretch – Movement Pattern Reinforcement 13 • Talocrural Complex – DorsiFlexion Functional – Glides • Subtalar Complex – Functional Glides • Subtalar Complex – Functional Glides • Midtarsal Complex – Self Stretch • Midtarsal Complex – Movement Pattern Reinforcement Rules of Thumb for Augmented Exercise Prescription • Consider Direction (Opening versus Closing, etc.) • Consider Hydration • Consider C id A Activation ti ti – Functional Arthrokinematic – Stretch – Movement Pattern Support – General Activation – Psychological Support 14 SensoriMotor Learning Processes Processes are associated with practice or experience leading to inferred, relatively permanent changes in the capability for movement • • • • Target Æ Skilled action Platform Æ practice or experience Assessment Æ Results of Learning Duration Æ relatively permanent changes in the capability for skilled behaviors Schmidt RA, Lee T. Motor Control and Learning - 4th : A Behavioral Emphasis. Human Kinetics, 2005 Thank You! Questions? 15
