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INDICATIONS OF MANUAL MEDICINE PART 2
In Part one,
you were familiarized with all of the types of medical conditions, which
can simulate an injured joint in need of rehabilitation. Situations
where there are co-conditions, which make you responsible for both
medicine, and the applications of manual medicine, an aspect of the
total health care would be application for an acute trauma absent any
connection with the underlying condition or contraindicated.
As you will see on the Auto Part 7 Human biomechanics, it has
been firmly established that the spinal column offers an intricate lever
system associated with prime movers, muscles, as well as the primary and
the secondary stabilizers the ligaments, tendons and other bones. This
biomechanics system allows the biped to move about efficiently under the
forces of gravity especially while carrying external loads. Oftentimes
if the body is unable to balance the centers of load with the forces
experienced especially performing repetitive activities, postural
stresses, or strains with associated reflex tensions may occur. There
may be combinations of incidents where joints are overworked, jammed or
stretched, strained, and/or sprained and possibly deformed. This
“jamming” (joint compression), overexertion (injury to the joint
beginning during or within their physiological range of motion), or
extension (injury to the joints beyond their physiological range of
normal motion including axial traction) and again combinations produce
insidious complaints of human suffering.
Upon biomechanical examination discovery may include
joint restrictions and excessive joint motion not limited to joint
instability. When we record the range of motion findings noting any
limitations with pain responses and to what degree, or absence of pain
response, the examiner is assessing osteokinematic motion which is the
movement that occurs between bones. Yet a sound biomechanical
examination assess the arthrokinematic movements that occur between
joint surfaces. Accessory movements are those arthrokinematic movements
that must occur in order for normal osteokinematic movement. While
assessing arthrokinematic movements the examiner notes joint play
motions. Joint play movements are those accessory movements that can be
produced passively at a joint but cannot be produced actively. Note
those restrictions to your applied motion indicating the joint is in a
close packed position also known as maximal congruence. When a joint is
restricted in a closed packed position and a subsequent trauma occurs to
the joint, conditions such a fractures, dislocations, capsular tears and
so forth can occur.1
Conversely a joint is in a loose-packed position, which is less
stable and has more joint play; trauma could induce strains and sprains
to at the associated tissues about the joint. Thus, your forensic
biomechanical examination would include whether the joint in question is
closed packed or in maximal congruence, restricted, unstable or normal.
With this knowledge, one can than prognosticate joint status. Whether
manipulation could prevent a future serious injury, is a medically
necessary procedure, or rule out manipulable lesion.2 It is
amazing what person’s who allege knowledge in presentation of manual
medicine will indicate about the “human status of a joint under
scrutiny”! A forensic biomechanical understanding of the human body
is a priori to the study of manual medicine.
We have now established the fact that specificity in our knowledge;
examination and comprehension of human motion and response to
life are a priori. Gross range of motion established over estimated
normal with the degree of pain noted at that degree of motion yields a
good understanding of the Osteokinematic status of our patients.
However, too often moderate to severe sprain injury patients remains
chronic.
We now understand the fact that assessing the Arthrokinematic
movements during a biomechanical examination greatly assist the examiner
with further necessary specificity in understanding our patients’
Biomechanical status. Remember arthrokinematic movements occur between
joint surfaces where osteokinematic movements only assess movement
between bones. For normal osteokinematic movement to occur, accessory
movements must be normal. Again accessory movements were those
arthrokinematic movements which must occur in order for normal
osteokinematic movement. Noting arthrokinematic accessory movement such
as joint play motion and end feel are the harbingers of joint status.
Thus prior
to presenting Medical Narrative Report Writing or Examination, a more
comprehensive discussion of joint passive movements will be presented.
Arthrokinematic End Feel is the perception the biomechanical examiner
“feels” in the articulations as they reach the end of “normal” range of
motion. Gross obvious aberrant motions need not be discussed. However
a “proper evaluation of end feel can help the examiner to assesses the
type of pathology present to determine a prognosis for the condition and
learn the severity or stage of the problem”. End feels motions have
been broken down into three classic normal patterns and five classic
abnormal patterns. The three classic normal end feel patters are “Bone
to Bone, Soft-Tissue Approximation and Tissue Stretch”.
Bone to Bone
is a painless hard and unyielding compression” that stops further
movement. This end feel is likened to elbow and knee flexion where the
muscles stop movement. It has been reported that in ectomorphic
individuals with little muscle bulk, the end feel of the elbow flexion
might most often be bone-to-bone.
Tissue Stretch
is the most common type of normal end feel. This end feel can be
described as “spring” or at the end of the range of motion there is a
feeling of elastic resistance. It has been described as feeling “rising
tension”. Various tissue thicknesses are consistent with degree of
elasticity. For example the Achilles tendon stretch may be vary elastic
as compared to the slightly elastic wrist flexion. Major injury to
ligaments often causes a softer end feel until the tension is taken up
by other tendons, ligaments, bones, connective tissue and other
structures. Examples of Tissue Stretch are lateral rotation of the
shoulder and metacarpophalangeal joint extension. The five
classic abnormal end feels are “Muscle Spasm”, Capsular, Bone to Bone,
Empty and Spring Block”.
Muscle Spasm
is the most studied
pattern. Cyriax MD, the father of the classification of joint end feels
called Muscle Spasm effects the “vibrant twang”. It was a sudden
dramatic arrest of movement often accompanied by pain with the end feel
being sudden and hard. Muscle Spasm has been divided into early due to
inflammation and late due to instability and the resulting irritability
caused by movement.
Capsular
is very similar to tissue stretch save it also has been divided
into hard capsular when end feel has a "Thick" quality to it and soft
capsular when it is similar to normal but has restricted range of
motion. The hard capsular is seen in more chronic conditions and the
soft capsular is more often seen in acute conditions. The end feel is
likened to soft and boggy as the result of synovitis or soft tissue
edema. Then Bone to Bone
becomes similar to normal bone-to-bone end feel except
it occurs prior to normal end motion.
Empty end feel is detected when movement produces considerable pain. Examples
could be acute subacromial bursitis or a neoplasm.
Springy Block
end feel is similar to tissue stretch where there is a rebound effects
which usually indicates an internal derangement within the joint.
Examples are torn meniscus of the knee when it is locked or unable to go
into full extension.
References:
1.
Warwick and Williams, Gray’s Anatomy, 35th
British Edition, W.B. Saunders Company, pp. 400-4007
2.
Kessler R.M., Hertling D., Management of
Common Musculoskeletal Disorders. Harper & Row p. 86-90, 1983.
3.
Magee, Orthopedic Physical Assessment, 2nd
Edition, W.B. Saunders Company, pp. 12-13
4.
Harrison’s Principles of Internal Medicine
Ninth Edition
“The Health of the people is really the foundation upon which all their
happiness and all their powers as a State depend.” Benjamin Disraeli
by
Scott D. Neff DC DABCO
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