Manual Therapy and Therapeutic Exercise for Common Orthopedic Conditions and Functional Mobility: Summary 51
• Grade III : Larger amplitude motions into stiffness or muscle spasm to increase the range of motion • Grade IV : Smaller amplitude motions at the end range of stiffness to increase the range of motion Physiological Responses to Manual Therapy Manual therapy produces three types of responses: 1. Neurophysiological : Mediation of pain responses from peripheral and central nervous systems 2. Biomechanical : Changes in connective tissue length and stiffness 3. Interpersonal : "Placebo effect" from a therapeutic relationship FUNDAMENTAL MOVEMENT PRINCIPLES There are several key movement principles that form the foundation for understanding therapeutic interventions: • Proximal Stability with Distal Mobility : This principle applies to both functional mobility and athletics, emphasizing core stability as the ability to control trunk position over the pelvis to optimize force production and transfer. Proximal weakness leads to postural instability, imbalance, poor efficiency, and force production • Kinetic Chain : The human body functions as a series of interrelated links where movement of one segment affects proximal and distal segments: ○ Open Kinetic Chain (OKC): Movement where the distal segment moves freely, allowing for muscle isolation ○ Closed Kinetic Chain (CKC): Movement where the distal segment is fixed, creating eccentric muscle activity, co-contraction, decreased joint shear forces, and increased joint stability • Elements of Movement : Movement involves both passive elements (physiologic and accessory motion) and dynamic elements (strength, power, stability). The integration of MT and TE addresses all of these components KNEE JOINT: BIOMECHANICS AND CONDITIONS Knee Joint Biomechanics The knee joint functions to provide: • Movement: ○ Near full extension during walking/running: ■ Passive elements: Hamstring flexibility, posterior capsule, patellar gliding, femur/tibia gliding ■ Dynamic elements: Quad strength ○ Flexion: 80-90 degrees with stairs and 90-115 degrees with sitting in a chair: ■ Passive elements: Quad flexibility, anterior capsule/patellar tendon extensibility, patellar gliding, femur and tibia gliding
INTRODUCTION Rehabilitation professionals are experts in movement, addressing everything from limited range of motion to neurological dysfunction and kinetic chain sequencing. There is strong scientific evidence supporting the beneficial use of exercise in rehabilitation, making it an indisputable intervention . Recent research has demonstrated that pairing manual therapy with therapeutic exercise amplifies the individual effects of each intervention, creating a synergistic "2 + 2 = 5" effect that optimizes patient outcomes. MANUAL THERAPY OVERVIEW Manual therapy is defined as skilled hand movements intended to optimize effects including improved tissue extensibility, increased range of motion, mobilization of soft tissues and joints, muscle function changes, joint stabilization, pain modulation, and reduction of soft tissue swelling or movement restriction. Various types of manual therapy include: • Soft tissue massage/mobilization • Myofascial release
• Trigger point release • Strain-counterstrain • Mobilizations • High-velocity thrust manipulations Joint Movement and Mobilization Grades
Joint accessory movements (arthrokinematics) occur with physiologic movement and must be restored for normal mobility. LEARNING TIP! Clinicians should recognize the
importance of the concave-convex rule in understanding joint arthrokinematics: • When a concave surface moves on a convex surface, roll and slide occur in the same direction • When a convex surface moves on a concave surface, roll and slide occur in opposite directions This rule is crucial for decision-making when applying mobilization techniques.
The Maitland grading system for mobilizations is presented: • Grade I : Small amplitude motions at the beginning of the available range for pain modulation • Grade II : Larger amplitude motions with some resistance for testing joint play, pain relief, and increasing motion
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