Self-Mobilizations of the Hip with Belting Techniques · of the hip with belting techniques ......

10/22/2015

AAOMPT Conference Louisville 2015, Rett Nicolai, DPT FAAOMPT 1

SELF-MOBILIZATIONS OF THE HIP WITH

BELTING TECHNIQUES

Everett Nicolai, DPT, FAAOMPT

AAOMPT Conference Louisville 2015 Rett Nicolai, DPT FAAOMPT, Ola Grimsby Institute

SELF-MOBILIZATIONS OF THE HIP WITH BELTING TECHNIQUES

Objectives

Description

Anatomy & Physiology

Arthrokinematics vs Osteokinematics

Mobilization Overview

Regional Interdependencies

Techniques



Objectives

Quick review of anatomy and biomechanics

Understand regional interdependencies

Instruct patients to perform home techniques



Description of LectureThe hip is of central importance for regional interdependencies for the lumbar spine, SIJ, knee and ankle. Self-mobilizations are brilliant ways to prepare the patient for discharge.


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ANATOMY & PHYSIOLOGY


RANGE of MOTION (MaGee, 2008)

Flexion 120˚

Extension 10˚-20˚

Adduction 30˚

Abduction 30˚-50˚

External Rotation 40˚-60˚

Internal Rotation 30˚-40˚

ANATOMY & PHYSIOLOGYFunctional ROM Tie shoes (120˚ flexion)

Sit (112˚ flexion)

Squat (115˚ flexion, 20˚ abduction, 20˚ ER)



BonesFemur sits in a

socket formed

by the innominate


ANATOMY & PHYSIOLOGYFemoral AnglesColumn & Angle Anterior Antetorsion Angle Acetabular Angle


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Hip Joint Capsule Ischiofemoral ligament

Iliofemoral (Y) ligament

Pubofemoral ligament



Hip Joint

Type: Multi-axial, ball and socket joint

Acetabulum: faces lateral, anterior, inferior

Stable: deep socket, labrum, strong muscles(Byrne, Mulhall, Baker, 2010)



Other Anatomy of the Hip

Ligament Teres

Pulvinar Acetabulum (Fat Pad)

Labrum

Cartilage


OSTEOKINEMATIC VS ARTHROKINEMATIC MOVEMENT

Osteokinematic: Movement of Bone

Arthrokinematic: Movement of Joint


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To mobilize a CONCAVE surface:

A concave joint surface always moves in the same direction as the bone.

example: finger flexion

Push

BoneJoint Surface

X

X

Joint SurfaceBone



To mobilize a CONVEX surface:

A convex joint surface always moves in the opposite direction as the bone.

example: shoulder abduction.

Push

BoneJoint Surface

X

X

Joint Surface

Bone

Fix

Fix


Accessory motions (Glide)Translational glide is inversely

Proportional to congruence and

depth of concavity:

Hip has ~180˚, therefore glide .8 - 4.2 mm

(posterior glide) (Loubert et al, 2013)


Fix

Fix

Glide

Glide

X

X

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Mobilization Vectors (Grimsby, 2012)


Movement Neutral Hip 90˚ Flexed Hip

Flexion Posterior glide (in sagittal plane) Inferior glide (in sagittal plane)

Extension Anterior glide (in sagittal plane) Superior glide (in sagittal plane)

Abduction Inferior glide (in frontal plane) Anterior glide (in transverse plane)

Adduction Superior glide (in frontal plane) Posterior glide (in transverse plane)

Internal Rot. Posterior glide (in transverse plane) Inferior glide (in frontal plane)

External Rot. Anterior glide (in transverse plane) Superior glide (in frontal plane)

MOBILIZATION OVERVIEW

Contraindications (Grimsby 2012)

Spinal cord injury Upper motor neuron lesion with decreasing

neurological function Unrelenting non-mechanical pain Multi-level nerve root pathology Unrelenting night pain Local recent severe trauma


MOBILIZATION OVERVIEWPrecautions (Grimsby 2012)

Local infection Active cancer Osteoporosis Inflammatory disease Prolonged steroid use Hypermobility syndrome Connective tissue disease Systemic pathology



Indications Decrease pain, psychological effects Improve posture and locomotion Restore physiological ROM, reduce adhesions Neurophysiological effects / Recruitment Normalize hypertonicity / diminish guarding Regional interdependencies Improve strength Therapist is too petit, weak, or broken


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MOBILIZATION OVERVIEWMechanoreceptors


Type I (Ruffini Corpuscles)

Type II (Pacinian Corpuscles)

Type III (GTOs) Type IV (free nerve endings)

Location Superficial layers of joint capsule. Neck, hip, shoulder

Deep layers of capsule. Ls, foot, hand, TMJ.

Deep/superficial layers of joint ligaments. Superficial layers of lumbar capsule. Not in PLL, ALL, IL

Joint capsule, blood vessels, articular fat pads, dura, ALL, PLL, IL, connective tissue. Not in muscle, disc, cartilage, meniscus, nerve, synovial tissue

Adaptation Slow. Fires for 1 min Rapid. ½ second w refractory period before fires again.

Very slow. Non-adapting

MOBILIZATION OVERVIEWMechanoreceptors


Type I (RuffiniCorpuscles)

Type II (Pacinian Corpuscles)

Type III (GTOs) Type IV (free nerve endings)

Function Proprioception (beginning and end ranges and at rest). Tonic reflexogeniceffects. Inhibits pain via dorsal horn.

Kinesthesia with dynamic motion (beginning and mid range). Phasic reflexogenic effects. Inhibits pain via dorsal horn.

Reflexogenicinhibiton of muscle tone. Inhibits motor unit. Dynamic sensation firing at end range. Don’t inhibit pain.

Tonic reflexogeniceffects w activation. Fire at abnormal levels of stimuli. Chemically, thermal, or mechanically activated.

Treatment Stretch articulation (15 seconds) x3

Oscillation (1x/sec) just smile Remove stimulus


Collagen Deformity:

Oscillationversus

Stretch Articulation



Belting specificity


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MOBILIZATION #1:OSCILLATORY

TECHNIQUE video here


MOBILIZATION #2:STRETCH

ARTICULATION TECHNIQUE

video here


PRACTICAL APPLICATIONS

You know the science.

Let’s apply it.


REGIONAL INTERDEPENDENCIES

Relationships between seemingly unrelated impairments in remote anatomical regions may contribute to the patient’s primary symptom. (Wainner, et al, 2007)

Biomedical model: musculoskeletal, neurophysiological, somatovisceral, biopsychosocial responses. (Sueki, Cleland, Wainner, 2013)


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REGIONAL INTERDEPENDENCIESLimitation in Total Hip Motion Lumbar Pain: Lack of total hip rotation 80˚ for LBP; 87˚ for no pain. (Roach, et al, 2015)

Lumbar Pain: Limited ROM in all planes. (Burns, et al, 2011) (Mellin, 1990)

Lumbar Pain: Asymmetry in total hip rotation between hips 2.6˚ to 8.4˚. (Van Dillan et al, 2008); (Cibulka, 1999)

SIJ Pain: Asymmetry in total hip rotation. (Cibulka, et al 1998); (Warren, 2003)

Knee Pain: Overpronation (increased IR & adduction): PFP (Souza & Powers, 2009)


SELF-MOBILIZATION #1:LONG AXIS DISTRACTION, NON-WEIGHTBEARING


SELF-MOBILIZATION #2:LATERAL DISTRACTION, 0˚, NON-WEIGHTBEARING


SELF-MOBILIZATION #3:LATERAL DISTRACTION, 45˚, NON-WEIGHTBEARING


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SELF-MOBILIZATION #4:

LATERAL DISTRACTION, 0˚, WEIGHTBEARING



Limited Hip Flexion Lumbar Pain: Limited flexion. (Sjolie, 2004); (Mellin, 1988); (Zafereo, et al, 2015)

Knee Pain: Limited flexion: 34.8˚ for knee OA pain

37.4˚ was normal. (Cliborne, et al, 2004)












SELF-MOBILIZATION #6:INFERIOR GLIDE IN 90˚, (SAGITTAL PLANE), NWB


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POSTERIOR GLIDE IN 0˚, (SAGITTAL PLANE) WEIGHTBEARING


SELF-MOBILIZATION #7:INFERIOR GLIDE IN 90˚, (SAGITTAL PLANE), NWB



INFERIOR GLIDE IN 90˚, (SAGITTAL PLANE)

NON-WEIGHTBEARING



Limited Hip External Rotation Lumbar Pain: Limited ER (Mellin, 1990); (Cibulka, 1999)


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SELF-MOBILIZATION #11:SUPERIOR GLIDE IN 90˚, (FRONTAL PLANE)

NON-WEIGHTBEARING



ANTERIOR GLIDE IN 0˚, (TRANSVERSE PLANE)

WEIGHTBEARING



SUPERIOR GLIDE IN 90˚, (FRONTAL PLANE)

PARTIAL WEIGHTBEARING


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Limited Hip Internal Rotation Lumbar Pain: Limited IR. (Sjolie, 2004) (Vad, et al, 2003, 2004); lacks 21˚ (Murray, et al, 2009)

SIJ Pain: Limited IR: posterior rotated pelvis. (Cibulka, 1999); (Warren, 2003)

Knee Pain: Limited IR: < 17˚ for knee OA. (Currier, et al, 2007)

Ankle Pain: Limited IR: increased subtalar pronation. (Cibulka, 1999)












SELF-MOBILIZATION #13:INFERIOR GLIDE IN 60-90˚, (FRONTAL PLANE)

NON-WEIGHTBEARING



POSTERIOR GLIDE IN 0˚, (TRANSVERSE PLANE) NON-WEIGHTBEARING


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REGIONAL INTERDEPENDENCIESLimited Hip Extension Lumbar Pain: Limited extension -4.2˚ for LBP, 6.8˚ for no pain (Roach, et al, 2015); (Mellin, 1988, 1990); (Van

Dillen, et al, 2000); (Zafereo, et al, 2015)

Shortened hip flexor result in external flexor torque and increased metabolic costs. Shortening result in increased activation of low back musculature with resultant increased internal moment. Excessive activation may lead to early onset fatigue and decreased protection from shearing and torsional loading. (Roach, et al, 2015); (Vad, et al 2003)

SIJ Pain: Limited extension. (Eland, et al, 2002)

Knee Pain: Limited extension: -4˚ for PFP, 6˚ for normals. (Roach, et al, 2014)

Gluteus Maximus: anterior glide in neutral; 14% increase strength. (Yerys, et al, 2002)












SELF-MOBILIZATION #15:ANTERIOR GLIDE IN 0˚, (SAGITTAL PLANE)

NON-WEIGHTBEARING



ANTERIOR GLIDE 0˚, (SAGITTAL PLANE) WEIGHTBEARING


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SELF-MOBILIZATION #16:SUPERIOR GLIDE IN 90˚, (SAGITTAL PLANE)

PARTIAL WEIGHTBEARING



Limited Hip Abduction Gluteus Medius: inferior glide in neutral; 17% increase strength (Makofsky, et al, 2009)








Abduction Inferior glide (in frontal plane)Medial glide (in sagittal plane)

Anterior glide (in transverse plane)




SELF-MOBILIZATION 17:

MEDIAL GLIDE IN NEUTRAL, WEIGHTBEARING


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Neurophysiological, Somatovisceral, Radicular Pain Joints’ mechancoreceptors influence motor unit activation, therefore muscle

function. It may increase strength by removing the reflexogenic inhibition from mechanoreceptors. (Makofsky, et al, 2009); (Warmerdam, 1985); (Wyke, 1985); (Yerys, et al, 2002); (Grimsby, 2012);

While simultaneously defacilitating through reciprocal innervation. (Yerys, et al, 2002)

Hypoalgesia effects after mobilization (Bialosky, Bishop, George, 2008)



These people may never have problems…


MOBILIZATION TECHNIQUESProblem Solving for Self-Mobilization Techniques Safety, don’t articulate in close-packed position Lack equipment (belt or stable fixture) Poor set-up position (individual’s posture or where the belt is) Loss of contact point pressure, fix & support one bone Incorrect vector Incorrect force Incorrect amplitude Patient not relaxed, motor moron


References:Grimsby O. Ola Grimsby Institute, Residency Program Curriculum 2006.Grimsby O. Ola Grimsby Institute, Fellowship Program Curriculum 2008.Grimsby O. Ola Grimsby Institute, PhD Program Curriculum 2012.

Rivard JR, Grimsby O. Science, Theory and Clinical Application in Orthopaedic Manual Physical Therapy: Vol 3: Scientific Therapeutic Exercise Progressions (STEP): The Back and Lower Extremity. Taylorsville, UT: Academy of Graduate Physical Therapy Inc.; 2008.

MaGee, D. Orthopedic Physical Assessment, 5th ed. St Louis, MO: Saunders Elsevier; 2008; 659-726.

Warmerdam A. Arthorkinematic Therapy: Improving Muscle Performance through Joint Manipulation. Wantagh, NY: Pine Publications, 1999; 32-44.

Wyke BD. Articular Neurology. In: Glasgow EF, Twoney LT, Scull ER, Kleynhans AM, eds. Aspects of Manipulative Therapy. New York: Churchill Livingstone, 1985; 72-77.

Sueki DG, Cleland JA, Wainner RS. A Regional Interdependence model of musculoskeletal dysfunction: Research, Mechanisms, and Clinical Implications. J Man Manip Ther. 2013; 21 (2): 90-102.

Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports PhysTher. 2007; 37(11): 658-660.

Byrne DP, Mulhall KJ, Baker JF. Anatomy & Biomechanics of Hip. Open Sports Medicine J. 2010; 4: 51-57.

Roach SM, San Juan JG, Suprak DN, Lyda M, Boydston C. Patellofemoral Pain Subjects Exhibit Decreased Passive Hip Range of Motion Compared to Controls. Int J Sports Phys Ther. 2014; 9 (4): 468-175.

Cliborne AV, Wainner RS, Rhon DI, Judd CD, Fee TT, Matekel RL, Whitman JM. Clinical Hip Tests and a Functional Squat Test with Knee Osteoarthritis: Reliability, Prevalence of Positive Test Findings, and Short-Term Response to Hip Mobilization. J Orthop Sports Phys Ther. 2004; 34 (11): 676-85.


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References:Roach SM, San Juan JG, Suprak DN, Lyda M, Bies AJ, Boydstom CR. Passive Hip Range of Motion is Reduced in Active Subjects with Chronic Low Back Pain Compared to Controls. Int J Sports Phys Ther. 2015; 10 (1): 13-20.

Van Dillen LR, Bloom NJ, Gombatto SP, Susco TM. Hip Rotation Range of Motion in People with and without Low Back Pain Who Participate in Rotation-Related Sports. Phy Ther Sport. 2008; 9 (2). 72-81.

Burns SA, Mintken PE, Austin GP, Cleland J. Short-Term Response of Hip Mobilizations and Exercise in Individuals with Chronic Low Back Pain: A Case Series. J Man Manip Ther. 2011; 19 (2). 100-107.

Makofsky H, Panicker S, Abbruzzese J, Aridas C, Camp M, Drakes J, Franco C, Sileo R. Immediate Effect of Grade IV Inferior Hip Joint Mobilization on Hip Abduction Torque: a Pilot Study. J of Man Manip Ther. 2007; 15 (2): 103-111.

Yerys S, Makofsky H, Byrd C, Pennachio J, Cinkay J. Effect on Mobilization of the Anterior Hip Capsule on Gluteus Maximus Strength. J Man Manip Ther. 2002; 10 (4): 218-224.

Loubert PV, Zipple JT, Klobucher MJ, Marquardt ED, Opolka MJ. In Vivo Ultrasound Measurement of Posterior Femoral Glide during Hip Joint Mobilization in Healthy College Students. J Orthop Sports Phys Ther. 2013; 43 (8): 534-541.

Crow JB, Gelfand B, Su EP. Use of Joint Mobilization in a Patient with Severely Restricted Hip Motion Following Bilateral Hip Resurfacing Arthroplasty. Phys Ther. 2008; 88: 1591-1600.

Bialosky, JE, Bishop MD, George SZ. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. Letter to the Editor. J Orthop Sports Phys Ther. 2008; 38 (3): 159-160.

Souza RB, Powers CM. Differences in Hip Kinematics, Muscle Strength, and Muscle Activation Between Subjects with and without Patellofemoral Pain. J OrthopSports Phys Ther. 2009; 39 (1): 12-19.

Powers CM. The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective. J Orthop Sports Phys Ther. 2010; 40 (2): 42-51.


References:Warren PH. Management of a Patient with Sacroiliac Joint Dysfunction: A Correlation of Hip Range of Motion Asymmetry with Sitting and Standing Postural Habits. J Man Manip Ther. 2003; 11 (3): 153-159.

Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral Hip Rotation Range of Motion Asymmetry in Patients with Sacroiliac Joint Regional Pain. Spine. 1998; 23 (9): 1009-1015.

Cibulka MT. Low Back Pain and Its Relation to the Hip and Foot. J Orthop Sports Phys Ther. 1999; 29 (10): 595-601.

Mellin G. Correlations of Hip Mobility with Degree of Back Pain and Lumbar Spinal Mobility in Chronic Low-Back Pain Patients. Spine. 1988; 13 (6): 668-670.

Mellin G. Decreased Joint and Spinal Mobility Associated with Low Back Pain in Young Adults. J Spinal Disord. 1990; 3 (3): 238-243.

Vad VB, Bhat AL, Basrai D, Gebeh A, Aspergren DD, Andrews JR. Low Back Pain in Professional Golfers: the Role of Associated Hip and Low Back Range of Motion Deficits. Am J Sports Med. 2004; 32 (2): 494-497.

Val VB, Gebeh A, Dines D, Altchek D, Norris B. Hip and Shoulder Internal Rotation Range of Motion Deficits in Professional Tennis Players. J Sci Med Sport. 2003; 6 (1): 71-75.

Reiman MP, Matheson JW. Restricted Hip Mobility: Clinical Suggestions for Self-Mobilization and Muscle Re-education. Int J Sports Phys Ther. 2013; 8 (5): 729-740.

Murray E, Birley E, Twycross-Lewis R, Morrissey D. The Relationship between Hip Rotation Range of Movement and Low Back Pain Prevalence in Amateur Golfers: an Observational Study. Phys Ther Sport. 2009; 10 (4): 131-135.

Sjolie AN. Low-Back Pain in Adolescents is Associated with Poor Hip Mobility and High Body Mass Index. Scan J Med Sci Sports. 2004; 14 (3): 168-175.

Eland DC, Singleton BS, Conaster MS, Howell JN, Pheley AM, Karlene MM, Robinson JM. The “Iliacus Test”: New Information for the evaluation of hip extension dysfunction. JAOA. 2002; 102 (3): 130-142.


References:Van Dillen LR, McDonnell MK, Fleming DA, Sahrmann SA. Effect of Knee and Hip Position on Hip Extension Range of Motion in Individuals with and without Low Back Pain. J Orthop Sports Phys Ther. 2000; 30 (6): 307-316.

Currier LL, Froehlich PJ, Carow SD, McAndrew RK, Cliborne AV, Boyles RE, Mansfield LT, Wainner RS. Development of a Clinical Prediction Rule to Identify Patients with Knee Pain and Clinical Evidence of Knee Osteoarthritis Who Demonstrate a Favorable Short-Term Response to Hip Mobilization. Phys Ther. 2007; 87 (9): 1106-1119.

Zafereo J, Devanna R, Mulligan E, Wang-Price S. Hip Stiffness Patterns in Lumbar Flexion or Extension Based Movement. Arch Phys Med Rehabil. 2015; 96 (2): 292-297


Self-Mobilizations of the Hip with Belting Techniques · of the hip with belting techniques ......

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