Clinical Notes in Physiotherapy

As previously stated, mechanical classification drives the intervention. In a derangement syndrome, the primary objective of intervention are to reduce the internal displacement, maintain the reduction, and restore full movement. In a dysfunction syndrome, the primary objectives are to remodel adaptively shortened tissues and reduce movement restrictions. The objective of intervention for patients presenting with a postural syndrome is to remove abnormal stresses on normal tissues. Upon subsequent visits, if the patient's symptoms are worse, or not improved, compliance and technique are checked before assuming an incorrect mechanical diagnosis has been made. Confirmation of the classification should be determined within five sessions. When performing exercises, the sequence of force progression begins with "patient-generated forces" that take place in midrange with eventual progression to end range and end range with self-overpressure. Once patient-generated forces have been exhausted, intervention may progress to "clinician-generated forces", which involves assisting the patient with movement from midrange to end range with therapist overpressure. Lastly, this approach espouses the use of prophylactic measures designed to equip patients with the knowledge and activities to prevent and manage future episodes by using "first aid" exercises.

PRINCIPLES OF INTERVENTION

If testing fails to identify a mechanical disorder, other tests may be performed to ascertain the potential contribution from adjacent regions. Such procedures include sacroiliac joint screening and hip joint assessment. Within this approach, these conditions are recognized.

Although not routinely performed, static tests may be necessary if repeated movement testing is inconclusive. Additionally, static tests may be preferable for patients with acute deformity or severe pain or when a postural syndrome is suspected. Selected positions include sitting erect, sitting slouched, long sitting, standing erect, standing slouched, or lying prone in extension.

Test movements Repeated movements in the offending direction are immediately abandoned if peripheralization of the symptoms remain after testing. If symptoms are improving or centralizing during repeated movement testing, the examiner should continue to see if the symptoms can be completely abolished. If symptoms are significantly reduced or abolished during movement testing in the prone position, it is important to have the patient rise from the table while maintaining a lordosis to determine if the symptoms remain improved in full weight-bearing. Maintenance of improved symptoms upon assumption of a weight-bearing posture is an indicator of a reducible derangement. If there is no conclusive symptomatic or mechanical response to sagittal plane movements, a laterally displaced derangement may be present. Repeated movement testing should then be performed with a lateral bias, such as extension in lying position with the hips displaced laterally to one side, then the other, or side gliding in the standing position.

The sequence of repeated movement testing :

Test Movements The use of repeated movement testing during the examination is one of the distinguishing features of the MDT approach. The patient's symptomatic and mechanical response to loading guides the examiner to the appropriate classification and course of intervention.

Postures "Standing" When the patient is standing, posture is assessed in the frontal and sagittal planes. The presence of a reduced or accentuated lordosis is noted. If pain is reported in standing, the location is recorded as well as any response to postural correction. Chronic deviations, such as scoliosis, may be present but have no effect on symptoms. Acute deviations, such as a lateral shift, also known as an acute lumbosacral or sciatic scoliosis, may also be present. This postural deviation is nonstructural and is caused by pressure on a nerve root from a disk herniation or other space-occupying lesion. The lateral shift is named by the direction in which the upper torso is displaced. The criteria for confirming the presence of a lateral shift that is relevant to the current condition includes the following : (1) the deformity is clearly visible (2) the onset is concurrent with the present episode of pain (3) the lateral shift cannot be voluntarily corrected or maintained (4) both flexion and extension movements are painful in weight-bearing (5) the pain is worse in standing or walking than it is when lying down. If a lateral shift is confirmed during the examination, lateral shift correction techniques should be commenced prior to initiation of repeated movement testing and intervention. Poor tolerance for repeated movements is often noted in the presence of a lateral shift.

Postures "Sitting" The patient's posture is grossly assessed while the examiner is obtaining the subjective history. If pain is reported in sitting, the location of the pain is recorded. The examiner corrects any aberrant postures (Fig. 9-9a) and monitors the patient's response to postural correction. If symptoms are reduced, the patient is educated on how to reproduce this posture, including the use of a lumbar roll (Fig. 9-9b).

PRINCIPLES OF EXAMINATION