Principles of Neuromusculoskeletal Treatment

• Where do we start with management?

  • Diagnosis
  • Specific vs non-specific
  • Stage & SIN
  • Dominant Pain Mechanism
  • Patients Problems
  • Tissue Healing – pathology, tissue healing time frames
  • Other factors? Yellow flags, Psychosocial
  • We must always be able to justify and reason why we are doing or giving a treatment/exercise
• Consider the Context

  • The person, psychosocial factors, mood, distress and other yellow flags, work and family demands
  • Ensure decision making is shared and the goals of treatment reflect the patients goals and are SMART
  • Consider wider healthy lifestyle factors. Encourage regular physical activity

  
• Consider the context:

  • Why is the person here
  • What are their goals
  • What are their expectations
  • Psychosocial influences
• Advice and education:

  • Explain what is wrong and what the patient can expect (natural history)
  • Address fears and unhelpful beliefs
  • Relative rest, encouragement of early (safe) return to activity
  • Discuss likely frequency/ duration of treatment, self-management plan
  • Discuss patients goals, treatment options, and encourage shared decisions

  
• Symptom control

  • Ask about pain control
  • Possible use of passive modalities
  • Consider analgesics (via qualified provider)
  • Other strategies

  
• Symptom Control – Manual therapy

  • Soft tissue treatment techniques
  • Massage, trigger point release
  • Passive joint techniques
  • Joint mobilisation, Joint manipulation
  • Two main mechanisms for their effect
  • Mechanical Stimulus
  • Neurophysiological
• Symptom Control - Manual Therapy – Mechanical stimulus

  • Biomechanical Effects
  • Transient without long lasting change
  • Main mechanism is to impact stiffness when it is a barrier to recovery
  • We are likely impacting tissue extensibility/viscoelastic properties
  • Current evidenced based practice has moved away from structural changes
  • We are not putting things back in or feeling if they are out
• Symptom Control - Manual Therapy – Neurophysiological Mechanism

  • Hypoalgesia effect:
  • Peripheral Mechanisms
  • Spinal Cord mechanisms
  • Supraspinal mechanisms

  
• Symptom Control - Manual Therapy – Peripheral Mechanisms

  • Potential Interaction with the peripheral nervous system
  • Alters the inflammatory mediators
  • Potentially influencing nociception
• Symptom Control - Manual Therapy – Spinal Cord mechanisms

  • Impacts on the activation of the Dorsal Horn
  • Pain gate: nonthreatening sensory input low-threshold Aβ fibres that inhibit nociceptive input from Aδ and C afferent fibres
  • Resulting an analgesic/hypoalgesia
  • Neuromuscular response
  • Changes in afferent activity alters muscle activity
  • Facilitating movement helps reassure patient as well as causing a neurophysiological response decreasing muscle tone helping to restore normal movement patterns
• Symptom Control - Manual Therapy – Supraspinal Mechanisms

  • Potential to impact via supraspinal mechanisms
  • Autonomic and opioid response
  • ACC, amygdala (emotion), PAG, RVM
  • PAG and RVM impact the Descending modulatory circuits – modulate nociception and pain output
  • Placebo, expectation and psychological factors (ACC and amygdala)
  • Relaxation impacts on your nervous system
  • Placebo can be extremely powerful
• Symptom Control - Applying Manual Therapy

  • Accessory mobilisations
  • Physiological mobilisations
  • How can we modify how we do them
  • Amplitude & Rhythm
  • Duration and repetitions
  • Direction
  • Patient Position
• Symptom Control - Contraindications / precautions to Manual Therapy (part 1):

  • Active Cancer
  • Osteoporosis
  • Rheumatoid arthritis
  • Active inflammatory or infective arthritis
  • TB
  • Unremitting night pain/unexplained weight loss
  • Long term corticosteroid or anticoagulant medications
• Symptom Control - Contraindications / precautions to Manual Therapy (part 2):

  • Pregnancy
  • Delayed or non union of fracture
  • Hyper mobility
  • Acute trauma (fractures, open wounds, sprains)
  • Congenital or acquired malformations
  • Acute inflammation
  • Hemarthrosis
  • DVT
  • Disc herniation
• Symptom Control - Manual Therapy in Summary:

  • Can be useful in assessment AND treatment
  • Short term effect
  • Use SIN and limiting factor (stiffness or pain) to decide appropriate technique
  • Use outcome measure to decide effectiveness e.g., Pain VAS, ROM, functional task
  • Used in combination with active treatment
• Build capacity:

  • Address:
  • Restriction in joint movement
  • Strength deficit
  • Control/ balance/ proprioception
  • Apply clear evidence based principles of exercise dose and progression

  
• Build capacity:

  • Always keep assessment problem list + shared goals as the focus
  • Reduce/remove impact of impairment
  • Enhance tissue healing
  • Provide systematic progression of ROM + STRENGTH
  • Restore function + remove disability
• Considerations when building capacity?

  • FITT principles
  • What are you aiming to improve:
  • Passive and active range of motion
  • Muscle strength vs Muscle endurance
  • Cardiovascular
  • ACSM guidelines
  • Specificity
  • Overload
  • Progression
• Building Capacity Considerations - Load

  • Load = The amount of demand placed on the system
  • Many types of load in the body:
  • tensile
  • friction/sheer
  • compressive
  • combination
• Building Capacity Considerations - Load

  • Internal Loads: how the individual perceives load / effort
  • External Loads: objective measurement of training quantity
• Return to function:

  • Advanced rehab
  • Functional/ sports specific exercise
  • Increase load
  • Consider appropriate level and time for return to function (particularly with high performance activities)

  
• Return to Function - Advanced rehab

  • Follow up Assessment
  • Activity specific questions
  • Assists and guides rehab goals and functional progressions
• Return to Function - Activity or Sport Specific Questions

  • Demands of that role
  • Equipment used and any recent changes
  • Skill Level
  • Any note in loss of function or performance
  • Competition Phases: where are they in their year and what is coming up
  • Training history: preseason & in-season management and percentage of completion