Principles of Neuromusculoskeletal Treatment

• Diagnosis – specific vs nonspecific 

  Stage & SIN (severity, irritability, nature) 

  Dominant pain mechanism 

  Patients problems 

  Tissue healing – pathology, tissue healing time frames 
• 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. 
• 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 – Passive/other strategies  

  Manual Therapy 

  • Manual techniques have been largely influenced by some key Physiotherapists  
  • Originally was very biomechanical/pathoanatomical based 
  • Current evidence indicates a move away from this traditional approach  
  • Used to be a mainstay of MSK management however in contemporary evidence-based practice, it is used as a small part of management if it is indicated 
• Soft tissue treatment techniques - Massage, trigger point release 

  Passive joint techniques - Joint mobilisation, Joint manipulation 

  Two main mechanisms for their effect  

    - Mechanical Stimulus  

    - Neurophysiological 

   
• 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 
• Neurophysiological Mechanism 

  Hypoalgesia effect 

  Peripheral Mechanisms  

  • Potential Interaction with the peripheral nervous system 
  • Alters the inflammatory mediators 
  • Potentially influencing nociception 
• Neurophysiological Mechanism 

  Hypoalgesia effect  

  Spinal Cord mechanisms 

  • Impacts on the activation of the Dorsal Horn 
  • Pain gate: nonthreatening sensory input low-threshold Aβ fibers that inhibit nociceptive input from Aδ and C afferent fibers 
  • 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 
• Neurophysiological Mechanism 

  Hypoalgesia effect  

  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 
• Applying Manual Therapy: 

  Accessory mobilisations  

  Physiological mobilisations  

   

  How can we modify how we do them; 

  Amplitude & Rhythm  

  Duration and repetitions  

  Direction  

  Patient Position 
• 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 

   
• Building capacity: 

  Reduce/remove impact of impairment  

  Enhance tissue healing  

  Provide systematic progression of ROM + STRENGTH 

  Restore function + remove disability 
• Considerations when building capacity: 

  FITT 

  Specificity 

  Overload 

  Progression 

  What to improve - Passive and active range of motion, Muscle strength vs Muscle endurance, Cardiovascular 
• Building Capacity Considerations - Load  

  How much can we load our patients?  

  Load = The amount of demand placed on the system  

   

  Many different types in the body.  

  • Tensile  
  • Friction/Sheer  
  • Compressive  
  • Combination   

   

  Internal Loads: how the individual perceives load / effort – RPE scale, 1-10 

  External Loads: objective measurement of training quantity 
• Return to function:  

  Advanced rehab  

  Functional/ sports specific exs Increase load  

  Consider appropriate level and time for return to function (particularly with high performance activities) 
• Designing a program “Sessions/Programs there are infinite, principles there are few”  

  Progressive overload 

  • Training must stress the enough to induce adaptation (but not too much!)  
  • S.A.I.D principle: Specific Adaptation to Imposed Demand  
  • Volume and intensity 
  • Rest: During and between sessions  

   

  Specificity  

  • Design the program for the person in front of you  
  • Endurance vs power vs speed vs endurance  

   

  Reversibility  

  • If there is insufficient stress, deconditioning will occur 
• Contributing Factors to rehabilitation: 

  Stressors 

  • Training  
  • Psychosocial factors  
  • Environmental: work, financial, lack of support   
  • Yellow Flags  
  • Unrealistic goals  

   

  Recovery  

  • Nutrition   
  • Hydration  
  • Sleep  
  • Positive support network  
  • Absence of stress  
  • Realistic Goals 
• Summary: 

  • Always have a clear aim of why you are giving a program and exercise  
  • Always relate it to the patient’s motivation and goals  
  • Number of exercises  
  • Less is more  
  • Prescription: relate always to the aim of the exercise  
  • Rest: Don’t forget it!