Dr Satyajit Mohanty blogs

The axial distraction mobilization techniques are frequently employed for treating patients with joint hypomobility. To know the biomechanical effects 3 different positions of glenohumeral abduction on a fresh cadaveric specimen ware chosen. They are 1. resting position 2. neutral position 3. end-range position Result indicated that displacement of the humeral head ware as follows: 1. largest in the resting position (27.38 mm) 2. followed by the neutral (22.01 mm) 3. and the end range position (9.34 mm). Greater gain in mobility was obtained in distraction at the end range position. During distraction mobilization, the force applied by the therapist and displacement of the humeral head depends on the joint position tested. These results also provide rationales for choosing end range distraction mobilization for improving joint mobility. Reference: Authors: Ar-Tyan Hsuab, Jing-Fang Chiuc, Jia Hao Changd

According to Vicenzino et al (2007) there are an increasing number of reports espousing the clinically beneficial effects of Mulligan's mobilization-with-movement (MWM) treatment techniques. The most frequent reported effect is that of an immediate and substantial pain reduction accompanied by improved function. Manual therapy effects on pain have been explained by many authors. The mechanism involved is thought to be an effect of mechanoreceptor response that affects the pain gait. Few others claim pain relief may be due to supra-spinal mechanisms based on opiate-like substance releases. However recent findings refer the supra-spinal mechanisms may not be involved especially spinal manual therapy-induced hypoalgesia. Naloxone antagonism and tolerance studies employ widely accepted tests for the identification of endogenous opioid-mediated pain control mechanisms. Paungmali et al (2004) reported that rapid initial hypoalgesia caused by Mulligan MWM was not antagonized by naloxone, ...

* This following information must be seen in the light of my previous 2 posts especially the last post. This class ends the series. 1. The vertebral body & the end plate: According to Prakash et al, many factors decide the integrity of the body of the vertebra. Gross design of the vertebral body is one of the most important adaptations for axial loading. The body of the vertebra is inter-segmental in origin, which results in dual vascular and nerve supply, both from superior and inferior aspects of the body. The vertebral body ossifies from 3 primary centers, one for centrum, which will form the major portion of body, and the other two for neural arches. The cartilaginous growth plate is mainly responsible for the longitudinal vertebral growth. 2. Intra-structural strength variation of end plates with specific reference to lumbar & sacral regions: Many studies indicate that some regions of the vertebral body may be stronger than others. Hence the failure strengths are different...

Introduction Schmorl’s nodes are nothing but protrusions of disc material into the surface of the vertebral body i.e. intraosseous disk herniation. It is named after German pathologist Christian Georg Schmorl (1861-1932). Schmorl's node can be detected radiographically but it is imaged better by CT or MRI. MRI is not only useful in detecting the recently developed Schmorl's nodes but also in differentiating between symptomatic and asymptomatic Schmorl's nodes (4). With reference to Schmorl’s nodes discs in MRI are generally noted for size, location, margins, internal and surrounding T1/T2 signal, adjacent disc herniation or bulge, concentric ring, underlying fracture including malignancy, infection, or prior disc surgery. The migrating disc material of a Schmorl’s node when comes in contact with the marrow of vertebra it leads to inflammation. Many times protrusions are also associated with necrosis of the vertebral bone. Whether these protrusions and inflammation cause the...

* The interveretbral disc is referred as disc in this following text Introduction: The intervertebral discs lie between the vertebral bodies, linking them together. The components of the disc are nucleus pulposus, annulus fibrosus and cartilagenous end-plates. The blood supply to the disc is only to the cartilagenous end-plates. The nerve supply is basically through the sinovertebral nerve. Biochemically, the important constituents of the disc are collagen fibers, elastin fibers and aggrecan. (3) The role that abnormalities play in the etiopathogenesis of different disorders is not always clear. Disorders may be caused by a genetic predisposition or a tissue response to an insult or altered mechanical environment. According to Roberts et al (2006), whatever the initial cause, a change in the morphology of the tissue is likely to alter the physiologic and mechanical functioning of the tissue (2) which is very important from all varieties (medicinal, physical therapy or surgical) of tre...

The treatment goal: To restore joint play & normalize roll-gliding that occurs in normal active physiological movements 1. Resting & actual resting positions: resting positions is otherwise called maximum loose pack position. In this position the capsule is lax maximally hence can accommodate maximum most fluid. a. The term actual resting position is used for special circumstances where it is impossible, impractical or difficult to use maximum loose pack position. b. Positional fault: Traction to decrease pain is usually performed form resting position. If it is difficult to perform traction from the resting position then the actual resting position is chosen. If traction to reduce pain performed from actual resting position produces pain then a positional fault is said to exist. c. Once this is found first aim is to perform glide-mobilizations to correct the positional fault & it is obvious that one must find the direction of glide that is restricted &...

Quotes from the legend: 1. The aim of examining movements is to find one or more comparable “signs” in an appropriate joint or joints. 2. Joint movements can never be classed as normal unless firm overpressure can be applied painlessly. 3. During examination and assessment pain should never be considered without relation to the range or vice versa. Performing the act: Different grades of movement are administered as oscillatory movements. Oscillatory movements have a positive & negative cycle. The positive portion of the cycle is one where impact of the force leads the accessory movement to sink into the tissues. Where as the negative portion of the cycle is one where, the therapist has to release the force to so that tissues can return to where it has started. Types of oscillatory movements: Oscillatory movements are administered in 1. Rhythmic manner or 2. With Irregular rhythm Under most circumstances the treatment used is regular & rhythmical. The informality...

Key points 1. In contrast to Maitland, Kaltenborn developed his joint play testing with an emphasis on straight line, translatoric movement within a joint. 2. The use of CCR (concave convex rule) for joint play testing. 3. The examiner feels for abnormal resistance to motion with a particular emphasis on end-feel testing. 4. This testing is not truly oscillatory although it is often repeated several times using different speeds of movement. Points to focus • Bone rotation = Joint Roll-glide = Physiological movement • Bone translation = Joint gliding, Traction, Compression = Joint play Rotation = curved movement around an axis, Translation = straight-line movement Kaltenborn’s 3 Point Scale Kaltenborn developed a 3 point scale to describe the amount of movement and perceived resistance during manual joint testing and treatment. Slackness available can be referred as the mid point form feeling point of view. When slackness is taken-up stretching (Gr-III) starts. Before ...

1. The intravertebral vacuum cleft sign (VCS) is an uncommon radiological sign. 2. VCS is characterized by a radiolucent zone in the vertebral body. 3. This zone is composed of 95% nitrogen and small amounts of oxygen and carbon dioxide. 4. Cause: a. Post-traumatic ischemic necrosis (main cause) but other causes are (point b onwards) b. osteoporosis, c. corticosteroid therapy, d. diabetes, e. arteriosclerosis, f. alcoholism, g. multiple myeloma, h. bone metastasis and i. osteomyelitis. The broad diagnosis is made by AP X-ray. However DD encompasses CT scan and MRI. Reference: Sarli M et al; Osteoporos Int. 2005 Oct;16(10):1210-4. Epub 2005 Feb 25.

1. Pain reduction by Grade I cephalo-caudal glide recommended (Wardsworth CT; Physical therapy, Vol.66, dec.1986) 2. Mid-range mobilization II, II(-), II (+) (no specific effects claimed up to yet except as a progression of grade I) 3. End- range mobilization Increase in mobility & functional ability by grade III,IV ( Henricus MV et al, PHYS THER, Vol. 80, No. 12, December 2000, pp. 1204-1213 and PHYS THER,Vol. 86, No. 3, March 2006, pp. 355-368) 4. Mulligan’s mobilization with movement (MWM) correct scapulohumeral rhythm significantly better than end range mobilization (Yang JL et al Phys Ther. 2007 Oct;87(10):1307-15) 5. PNF techniques for shoulder (Joseph JG et al; J Orthop Sports Phys Ther; Vol.33, dec. 2003 ) - for scapulo-humeral alterations 6. PNF for upper trunk (My recommendation: Satyajit Mohanty, MSPT- not supported by research i.e. on clinical experience only) for scapulo-humeral alterations + upper trunk kyphosis

Our peer’s classes on mobilization start with explanation of articular anatomy & McConnell joint classifications. It is followed by CCR with technique applications obeying the CCR. For shoulder mobilization it goes like this: 1. To regain ER – Anteriorly directed glides. 2. To regain ABD – Inferiorly directed glides 3. To regain IR – posteriorly directed glides Many times conventional wisdom is challenged when the research reports are contra posed. A paper JOSPT (2007) claimed that posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM in subjects with adhesive capsulitis. However in groups comprised of both anterior directed glides compatible to CCR and posterior glides opposite to CCR recommendation had a significant decrease in pain. Reference: Johnson AJ et al; J Orthop Sports Phys Ther. 2007 Mar;37(3):88-99.

Launder KG et al evaluated the acute effects of "sleeper stretches" on shoulder ROM. In their study sleeper stretches produced a statistically significant acute increase in posterior shoulder flexibility. However these authors explain that these acute changes in motion may not be clinically significant. Because of this recently expressed the belief that the sleeper stretch is better than the cross-body stretch to address glenohumeral posterior tightness because the scapula is stabilized McClure P et al compared changes in shoulder internal rotation range of motion (ROM), for 2 stretching exercises, the "cross-body stretch" and the "sleeper stretch," in individuals with posterior shoulder tightness. The sample consisted of 54 asymptomatic subjects (20 males, 34 females). The groups: 1. The control group (n=24) consisted of subjects with a between-shoulder difference in internal rotation ROM of less than 10 degrees. 2. Experimental groups ware those su...

The pioneers of joint play testing The two principal pioneers of joint play testing in manual therapy are Geoffrey Maitland of Australia, and Freddy Kaltenborn of Norway. Both individuals developed techniques for the extremities and spine, and both developed different scales for describing the force and movement used during testing and treatment. Essential Differences between the Australian and the Nordic Approach During the development of his approach, Maitland was strongly influenced by the neurophysiologic principles relating to pain. Kaltenborn on the other hand was influenced by the joint based mechanical approaches advocated by Cyriax, Mennel, and Stodard. 1. Basic differences in approaches: Maitland’s approach (non-diagnostic approach): Maitland’s approach uses angular motions in the extremities when looking at joint play. Logically, angular movements of the long bones may be used to identify abnormal resistance due to muscle guarding, muscle tone, or articular restriction. How...

Grades of accessory movement This following article is about introducing the novice manual therapist to grades of applying passive accessory movement. Variables of Passive accessory movement administration 1. Direction 2. Grade 3. Speed & Rhythm 4. Duration of administration Aim of grading of passive accessory movements 1. To assess: Different abnormalities of spine & periphery presents with different amount of pain & resistance to passive movements. Our approach to palpation can not be the same to all of them as there may be different grades of tolerance to forces due to either mechanical faults or inflammation. a) Hence first of all force identified into different grades provides a rational explanation to approach tissue faults. b) It also helps to find out localized & referred pattern of pain (especially in spinal conditions). c) It further indicates tissue condition accessible at different depth of penetration (feel of the tissue). d) It als...