Properties of muscle nodules recognized by manual physical therapy practitioners

[Purpose] The purpose of this study was to describe the properties of muscle nodules (kinkoketsu) recognized by manual physical therapy practitioners. [Participants and Methods] A total of one hundred and thirty-three physical therapists, occupational therapists, judo therapists, and acupuncturists participated in this study. The shape, size, direction, depth, and hardness of muscle nodules, often treated in the buttocks, were investigated through the completion of a questionnaire. [Results] A total of 124 answer sheets were completed; 112 of these described the shape of muscle nodules as ellipsoidal. Of these 112 sheets, 97 effective sheets were analyzed. The results showed that the mean long axis length, short axis length, and thickness of the muscle nodules were 30.9 mm, 16.2 mm, and 9.3 mm, respectively. The most common responses on the long axis direction, depth, and hardness of the muscle nodules were the craniocaudal orientation, the second shallowest layer of 5 divisions, and the eraser level, respectively. [Conclusion] The typical muscle nodule found in the buttocks by manual physical therapy practitioners is roughly the shape of a large almond.

Cervico-cephalalgiaphobia: a subtype of phobia in patients with cervicogenic headache and neck pain? A pilot study

OBJECTIVES

The term 'cephalalgiaphobia' was introduced in the mid-1980s and defined as fear of migraine (attacks). We hypothesized that a specific subtype of cephalalgiaphobia affects patients with cervicogenic headache (CEH). This study aimed to: (1) define the term 'cervico-cephalalgiaphobia'; (2) develop a set of indicators for phobia relevant to patients with CEH; and (3) apply this set to a practice test in order to estimate the frequency of cervico-cephalalgiaphobia in the Dutch primary care practice of manual physical therapy.

METHODS

A systematic approach was used to develop a definition and potential indicators for cervico-cephalalgiaphobia. An expert group appraised the definition and the set of indicators (score per indicator: never; sometimes; often/always). An invitation to participate in the practice test was sent to Dutch manual physical therapy practices (n = 56) representing 134 manual physical therapists (MPTs). The cut-off point for percentages of scores for coverage of the indicators was set at ≥ 60%.

RESULTS

The expert group agreed with the proposed definition of cervico-cephalalgiaphobia. A set of eight indicators for cervico-cephalalgiaphobia was selected from 10 initial indicators. Thirty-six MPTs provided data from 46 patients diagnosed with CEH. The coverage of 'often/always' was substantial for the indicators, 'Short-term positive results in previous manual physical therapeutic treatment', 'Shorter interval between treatment sessions', 'Fear of "locked facet joints" of the neck', 'More frequent manipulation', and 'Fear of increase in headaches'. Coverage was also substantial for 'never' regarding 'Long-term positive results in previous manual physical therapeutic treatment'. 'Confirmation of "locked facet joints" of the cervical spine by MPT as a cause for increase of CEH' scored 'often/always' in all patients. Coverage for 'Increased use of medication with insufficient effect' was substantial, scoring as 'sometimes' in 39 (84.8%) patients.

DISCUSSION

Cervico-cephalalgiaphobia was defined and a set of eight indicators formulated based on the literature and clinical expertise. The practice test provides valuable information on the frequency of indicators for cervico-cephalalgiaphobia in the Dutch manual physical therapy practice, suggesting that cervico-cephalalgiaphobia is common in patients with CEH.

Manual physical therapy combined with high-intensity functional rehabilitation for severe lower extremity musculoskeletal injuries: a case series

OBJECTIVES

Severe lower extremity trauma accounts for large healthcare costs and often results in elective amputation and poor long-term outcomes. The purpose of this case series is to describe an orthopedic manual physical therapy (OMPT) approach combined with a return to run (RTR) clinical pathway consisting of high-intensity functional rehabilitation with a custom energy-storing orthosis.

METHODS

Three consecutive male patients, aged 21-23 years, with severe lower extremity musculoskeletal injuries were treated with a combined intervention that included a mean (SD) of 12 (2·1) OMPT sessions and 24 (8·7) functional rehabilitation sessions over a mean of 6 weeks (1·0). Additional training with a custom energy-storing orthosis consisted of a mean of 15 (1·2) additional sessions over 4 weeks. Patient self-report outcome measures and a variety of physical performance tests captured change in function.

RESULTS

Baseline lower extremity functional scale (LEFS) and foot and ankle ability measure activities of daily living subscale (FAAM-ADL) scores indicated severe disability. All patients exceeded the minimal clinically important difference (MCID) in at least one self-report outcome or physical performance test without a brace. Two of three patients exceeded the MCID for at least two physical performance tests after training with and utilizing a custom energy-storing orthosis.

DISCUSSION

Clinically meaningful changes in self-reported function or physical performance were observed in all patients. A multi-modal approach, including manual therapy and functional exercise, may address the entire spectrum of impairments in patients with severe lower extremity trauma, resulting in improvements in both braced and un-braced function.

Clinical decision-making in the management of cervical spine derangement: a case study survey using a patient vignette

BACKGROUND

Neck pain is one of the most common, potentially disabling, and costly musculoskeletal conditions seen in outpatient physical therapy (PT). Clinical decision-making involves referral or the selection of intervention based on the results of the PT examination. Despite evidence that suggests that treatment based classification is most efficacious, it is hypothesized that examination and intervention may be heavily influenced by post-graduate training experiences.

PURPOSE

The purpose of this study was to analyze which tests, measures, and interventions are most commonly selected by physical therapists (PTs) holding a credential from the McKenzie Institute and those holding the McKenzie credential plus the credentialc of Fellow of the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT). Their responses were based on a simulated case vignette involving a patient with a presentation of cervical spine disk derangement.

METHODS

A survey administered through Survey Monkey was sent to 714 members of the McKenzie Institute who are certified or hold a diploma in mechanical diagnosis and therapy (MDT) or these credentials with the addition of Fellowship credentialing (MDT+FAAOMPT). Of the 714 surveyed PTs, 83 completed the survey for a response rate of 11.6%. As the PTs were given further information regarding the patient, they were asked to progress through a clinical decision-making process by indicating their sequence of examination techniques, and then indicating which interventions would be performed based on the results of the examination.

RESULTS

A descriptive analysis was conducted to determine the most common sequences chosen by the PTs based on their training. To perform the analysis, only respondents who completed the survey were included: clinicians with MDT credentials, (n = 77), and clinicians with both the MDT and FAAOMPT credentials (MDT+FAAOMPT), (n = 6). Initially, the most common examination chosen regardless of credential was postural analysis. After receiving additional information regarding the patient's posture, the majority of clinicians in each of the three groups then chose active range of motion (AROM). However, after additional information was given, the majority of the MDT group chose repeated end range cervical movements as their next examination measure, and the FAAOMPT group varied. The majority of the FAAOMPT group continued to assess the patient through an entire examination sequence, while the majority of the MDT group discontinued testing. A descriptive analysis of the intervention sequences depicted a trend toward direction of preference (DP) exercises for the MDT group (80.3%), and passive movements or mobilization exercises for the FAAOMPT group.

CONCLUSION

The results of this study suggest that PTs with post-graduate training through the McKenzie Institute or through Orthopaedic Manual Physical Therapy (OMPT) Fellowship training may demonstrate an inherent bias toward their advanced training in the assessment and treatment of acute cervical derangement. Although no significant findings can be reported secondary to sample size limitations, future studies may be performed to further explore this topic.

The role and position of passive intervertebral motion assessment within clinical reasoning and decision-making in manual physical therapy: a qualitative interview study

Passive intervertebral motion (PIVM) assessment is a characterizing skill of manual physical therapists (MPTs) and is important for judgments about impairments in spinal joint function. It is unknown as to why and how MPTs use this mobility testing of spinal motion segments within their clinical reasoning and decision-making. This qualitative study aimed to explore and understand the role and position of PIVM assessment within the manual diagnostic process. Eight semistructured individual interviews with expert MPTs and three subsequent group interviews using manual physical therapy consultation platforms were conducted. Line-by-line coding was performed on the transcribed data, and final main themes were identified from subcategories. Three researchers were involved in the analysis process. Four themes emerged from the data: contextuality, consistency, impairment orientedness, and subjectivity. These themes were interrelated and linked to concepts of professionalism and clinical reasoning. MPTs used PIVM assessment within a multidimensional, biopsychosocial framework incorporating clinical data relating to mechanical dysfunction as well as to personal factors while applying various clinical reasoning strategies. Interpretation of PIVM assessment and subsequent decisions on manipulative treatment were strongly rooted within practitioners' practical knowledge. This study has identified the specific role and position of PIVM assessment as related to other clinical findings within clinical reasoning and decision-making in manual physical therapy in The Netherlands. We recommend future research in manual diagnostics to account for the multivariable character of physical examination of the spine.