COMBINED MOVEMENT THEORY

INTRODUCTION
• The concept of the combined movement theory was developed by – “ Brain Edward” who is the author of the “Manual of combined movement”

• DEFINITION- movement imparted on the spine as directed under the control of the therapist.

• There is a little use of the combined movements in the past.

• Common examples are- Spurling’s maneuver and Quadrant test.

• Combined movements are extremely useful in the management of the musculoskeletal disorders of the spine.

• Majority of individual’s normal daily activity involve complex movement through the range of cardinal planes rather than simple movements such as flexion, extension, rotation, and side flexion. e.g.- simple activity such as looking over the shoulder to reverse the car involves combination of movement – cervical rotation, lateral flexion, extension, lifting items into the car involves- lumber flexion, side flexion, rotation.

• So according to the Edward we should examine the patient through a similar combination of planes of movement to determine the true nature of patient dysfunction.

• In clinical practice there are many situations where movement in the cardinal planes is not provocative enough to reproduce the patient’s symptoms. This is common where the patient’s disorder is less severe and more of a nuisance problem. These patients can be difficult to treat because the therapist has little information to prescribe treatment and also nothing to re- evaluate for treatment effect. Hence combined movements can be used as a more provocative procedure to increase the stress on the spine to “chase the symptoms”. The therapist is then able to logically progress treatment using the combined movement theory and has a reassessment sign for treatment effect

• Combined movements will vary the mechanical stresses placed on the innervated structure of the spine( which includes the facet joint, disc, spinal ligament, muscle, dura, nerve). Hence it is possible to vary the patient’s symptoms both in intensity (strong pain- mild pain) and in distribution (local pain- referred pain) .For patients with severe pain and with disorders of a more serious nature it is possible to minimize the stress on the painful structures by using combined movement theory.

• It is apparent in clinical practice that end range Mobilization techniques are more effective than early range movements. Combined movement theory permits the use of a end range treatment technique throughout a treatment.

• Combine movement theory attempts to incorporate the biomechanics of the IV motion segment in examination and treatment.

DIFFERENCE BETWEEN COMBINED AND COUPLED MOVEMENT COUPLED MOVEMENT
• An involuntary movement that occurs in an unintended or unexpected direction during the execution of desired movement.
• Occurs naturally during all spinal movement
• Occur under the involuntary control.

COMBINED MOVEMENT
• Are movement imparted on the spine as directed under the control of the therapist.
• Combined movements don’t occur naturally.
• Occur under the voluntary control.

MOVEMENT PATTERNS
• The movement of the vertebral column are complex. The articulations are such that each vertebral segment when moved involves movement of three different joints -2 zygoapophyseal joints and disc .

• The shape of the articulation, the amount and type of the movement which is possible at each level is affected by the soft tissue structure between the bony articulation and the structure within neural foramina and vertebral canal.

• The movements of vertebral column do not occur in isolation but in a combined manner. Roland 1966, Loebi1973, found that axial rotation of the lumber spine was to the left when the subject bent to the left and to the right when the subject bent to the right. In case of coupled movement to the lumber spine the direction of the axial rotation may vary as stated by Pearcy and Tibrewal in 1984 and Stoddard in 1983 states that the direction of rotation during lateral flexion in the lumber and the thoracic spine will vary according to whether the lateral flexion is performed with the whole spine in flexion or extension. They suggested that the rotation is to the same side if the lateral flexion is performed in flexion, but in the opposite side when the movement is performed in extension. The direction of movement appears to be same regardless of whether the movement of lateral flexion is performed in flexion and extension.

EXAMINATION OF ROTATARY AND LATERAL FLEXION MOVEMENTS

• In varying position of flexion and extension will help in establish `the type of movement response present. Combing movement gives an indication as to the way of signs and symptoms changes, when the same movement is performed in flexion and extension.

• E.g. of combination of 2 movements is- The amount of rotation which is possible between cervical 2nd and 3rd vertebra will vary depending on the amount of flexion or extension when movement is performed.

• E.g. of combination of 3 movements is- lateral flexion and rotation can be carried out either in flexion or extension. It is also imp to realize that the sequence of performing the movement may be varied and produce different symptomatic response. This is because the movement which is performed first can reduce the available range of the 2nd movement and obviously the 3rd movement is restricted even further. So when using these combination of movement as examining movement care must be taken to ensure that each position is maintained while performing the next movements.

Various possible variation of sequence can be seen in this e.g. of flexion, lateral flexion, and rotation to the left of the cervical spine are-
1)Flexion, lateral flexion to the left, rotation to the left.
2)Flexion, rotation to the left, lateral flexion to the left.
3)Lateral flexion to the left, flexion, rotation to the left.
4)Lateral flexion to the left, rotation to the left, flexion.
5)Rotation to the left, flexion, lateral flexion to the left.
6)Rotation to the left, lateral flexion to the left, flexion.

Different movement of the spine- those in flexion, lateral flexion, rotation can cause similar stretching and compressing movement on the side of IV joint.

Combining movements of examination can therefore increase or decrease compressive or stretching effect on the IV segment. This result in recognizing movement response in the patients with mechanical disorder of movement.
These are

- Regular
- Irregular

REGULAR RESPONSE

These are responses in which similar movements at the IV joint produce the same symptoms whenever the movement is performed.
Tend to be single structure and non traumatic
E.g. discogenic; stretch/compressive pattern
facet joint; compressive
capsular; stretch
• Regular pattern is divided into -Compressing
-Stretching
• Compressing-If the patient symptoms are produced on the side to which the movement is directed then the response is a compressing response. i.e. the compressing movement produce the response.

e.g. - Right cervical rotation produces right suprascapular pain. This pain is worsen when the movement is performed in extension and eased when performed in the flexion.

- Right lateral flexion in the lumber spine produce right buttock pain. This is made worse when the movement is performed in the extension and eased when performed in flexion.

• Stretching response- if the symptoms are present on the opposite side from that to which the movement is directed.

e.g. - right lateral flexion in the cervical produce the left suprascapular pain. This pain is accentuated when the same movement is performed in flexion and eased when performed in extension.
- Right lateral flexion in the lumbar spine produced left buttock pain. This is accentuated when the movement of right lateral flexion in performed in flexion and eased when performed in extension.


• Combination of movement will increase or decrease the compression or stretch in a given area. this will predicted by using the following pattern.

• In flexion all the structure anterior to the line X( the axis about which the movement occur) will be compressed and all the structure posterior to the line Y will be stretched. In extension the reverse will be true. In side flexion to the left side the structure on the right side will be stretched.

• When the two movements are combined such as flexion and side flexion to the right all the structure on quadrant 1 will compressed maximally and all the structure in quadrant 3 stretch maximally. Quadrant 2 and 4 will have combination of stretch and compression which will have no combine effect.


IRREGULAR RESPONSE

All responses which are not regular, fall into the category of irregular response. With irregular response there is not the same consistency of symptoms and stretching and compressing movement do not follow any recognizable response. There is random reproduction of symptoms despite combining movement with similar mechanical effects.

e.g. 1- right rotation of the cervical spine produce right suprascapular pain (a compressing test movement). This pain is made worse when right rotation is performed in flexion stretching movement) and eased when the movement is performed in extension (a compressive movement).

e.g. 2- extension of the lumbar spine increase right buttock pain. When right lateral flexion is combined with this movement, the pain is decrease, but when left lateral flexion is combined with extension, the pain increased.

• Irregular pattern – tends to be multistructural and traumatic( e.g. following motor vehicle accident) e.g. combination of disc, capsular, ligamentous and intervertebral foramina.
• Irregular or inconsistent pattern are common where there is instability.


ESTABLISHING THE MOVEMENT PATTERN

1) SUBJECTIVE EXAMINATION

This part of the examination follow the principles describe by the Maitland. In this pattern recognition in encouraged. Particular emphasis is placed on determine a subjective directional related pattern of symptoms reproduction. In other words find the movement direction(eg flexion) or activities ( e.g. flexion activity such as putting shoes on) that most aggravate the patients symptoms. This will enable the Physical examination to be more precise and ensure that the patient problem is going to be address.
It is most important to determine the SEVERITY, IRRITIBILITY, NATURE ( SIN) of the patients presenting disorder. This information enables the therapist to examine and treat the patient without increasing symptoms when the patient has high SIN and make sure that more aggressive treatment is given when the patient has low SIN. In combined movement theory the SIN will determine the extent and vigour of the physical
Examination as well as starting position of the treatment.

2) PHYSICAL EXAMINATION

Examination of the plane active movement will determine the primary movement. This is the active movement that is most significant in reproducing the patients symptoms. This is important as it helps in determining the order in which combined movement testing is applied. The secondary movement is the additional movement which is added to the primary movement in the primary position.

The primary combination is that movement combination which is most comparable to the patients symptoms. This is the movement combination that brings on the patients symptoms more than any other movement combination.

The primary position is that point in range at which symptoms first begin. It is essential to take the primary movement to the onset or increase( in resting pain) and ensure
that primary movement is not altered when the secondary movement is added.

3) SEQUENCE OF TESTING

( Depending on the SIN of the presenting disorder). But in cases where the SIN is not a concern then the following testing procedure will be undertaken.
a) Primary movement, must be active.
b) Just after the onset of the pain (p1) add the secondary movement which should be active-assisted.
c) Determine the symptom response.
d) It is very important to give clear instructions to the patients particularly in respect to the response to the secondary movement. Is the patients pain “ better, worse or the same”. It is important to make sure that the primary movement is maintained while performing the secondary movement otherwise the interpretation of the patients response will be invalid.
e) It is also important to determine which pain is provoked by the combined movement, is it the patients pain they complain of or it is a new pain that they have never experienced before.

HOW TO RECORD THE INFORMATION
1)Suppose the patient has right sided low back pain which is indicated by the shading in the right lower quadrant.
2) The primary movement is extension which is indicated by the thick arrow pointing towards the extension. The length of the arrow indicates the range of movement available. Full range would be to the perimeter of the box.
3) The double headed arrow is the secondary movement and again the length of the arrow indicates the available range of motion.
4) The two arrows together indicate the primary combination.
Regular compressive pattern

PALPATION IN THE COMBINED MOVEMENT

Palpation in the combined position can be used to confirm or refute an hypothesised combined movement pattern.
The therapist would undertake the routine palpation of the cervical or the lumbar spine.
Common technique employed in the combined movement examination of the cervical and lumbar spine include central, unilateral PA, and transverse pressure AP are used in the cervical spine.
Recording palpation finding in combined positions

> The arrow on the left indicates a posterior- anterior pressure.
> L1-5 indicate the L1 to the L5 spinous process.
> Lines under each level indicates the amount of stiffness present at each level.
no lines- no stiffness normal
accessory glide
3 lines- maximum stiffness
2 lines- moderate stiffness
1 line- minimal stiffness.

Spiral line under the stiffness indicate pain.
no spiral – no pain.
a small spiral – mild pain
longer spiral- moderate pain
longest spiral- severe pain on
accessory glide

SELECTION OF TECHNIQUE
v Depend on all the factors including, irritability, severity, nature of the disorder( SIN).
v The lower the SIN the closer the treatment technique to the primary combination.
v The higher the SIN the further away the treatment technique to the primary combination. In general it is better to use a position that does not incorporate the primary movement. Primary movement can be added at later stages.

Patient category
Once the primary movement and primary movement combination have been established, the next point to be establish the category of the patient. It is establish after the full examination procedure, and it is useful in assisting with the selection of initial direction of the treatment techniques or position of patient at the beginning of the treatment programme.
Three categories are recognized and they are-
> ACUTE
> SUBACUTE
> CHRONIC

ACUTE CATEGORY-
a) Less than 48hrs onset.
b) Primary movement is less then half range.
c) Pain score is usually greater than 5 on a visual analogue scale (VAS) of 1-10.
d) May be irregular or regular movement response.
e) On movement diagram, pain, resistance and spasm are present and tend to be start before half range is reached. Usually limited by pain.
f) Symptoms are usually local, but can be referred.

SUBACUTE CATEGORY-
a) Onset is longer than 48hrs but less then 6weeks.
b) Primary movement is equal to, or greater than 6 weeks.
c) Pain score is equal to, or less than, 5 on VAS.
d) Regular movement response may be dominant, but an irregular movement response can still be present.
e) Movement diagram resistance start before half range is reached, pain and spasm are usually Present, but are minor. Limited by resistance.
f) Symptoms may be local or referred.

CHRONIC CATEGORY-
a) Onset is longer than 6 weeks.
b) Primary movement is greater than half range.
c) Pain score is less than 5 on VAS.
d) Regular response usually dominate.
e) Movement diagram show resistance starting early in the range. Pain graph is low. The limitation is always resistance.
f) Symptoms are local or referred. SELECTION OF INITIAL TREATMENT TECHNIQUE AND PROGRESSION OF TREATMENT
ACUTE CATEGORY-

In the acute category with regular or compressive movement, the direction of the initial procedure is always towards the opposite quadrant.
E.g.- a patient presenting with left buttock pain, with regular compressive movement response. Left lateral flexion is the primary movement, restricted to one quarter range. Left lateral flexion in extension is the primary combination restricted to one eighth range .the first tech chosen is RLF in flexion shown by three headed arrow.

PROGRESSION

ROUTE 1
( R ) LF In F
( R ) LF In E
( L ) LF In E

ROUTE 2
( R ) LF In F
( L ) LF In F
( L ) LF In E

Route 1 is probably less painful direction as it more gradually approach to primary combination.
Regular stretch responses for acute category- patient complain of left buttock pain. Flexion is the primary movement, and RLF performed in flexion is the primary combination. Symptoms are produced in the C quadrant. The starting position is LLF In E. PROGRESSION

ROUTE 1
( L ) LF In E
( L ) LF In F
( R ) LF In F

ROUTE 2
( L ) LF In E
( R ) LF In E
( R ) LF In F

Route 2 is less painful.
In the category of subacute and chronic regular stretch and compressive movement responses, the same principles can be used. The starting point may be closer to the primary combination, except where distal symptoms and neurological signs are present. In these cases, it is always best to start in the opposite direction and use the same progression as for the acute category.

SUBACUTE CATEGORY, REGULAR COMPRESSIVE MOVEMENT RESPONSE Symptoms fall into the C quadrant. Extension is the primary movement, LLF in extension is primary combination.
PROGRESSION

ROUTE 1
( R ) LF In N
( R ) LF In E
( L ) LF In E

ROUTE 2
( L ) LF In F
( L ) LF In N
( L ) LF In E

route 1 is less painful.

REGULAR STRETCH PATTERN

For left buttock pain. Symptom fall in quadrant C. flexion is the primary movement and right lateral flexion in flexion is the primary combination.

PROGRESSION

ROUTE 1
( L ) LF In N
( L ) LF In F
( R ) LF In F

ROUTE 2
( R ) LF In E
( R ) LF In N
( R ) LF In F
Route 2 is less painful.

CHRONIC CATEGORY
REGULAR COMPRESSIVE MOVEMENT RESPONSES

Pain in the left buttock. Primary movement is extension. And primary combination is left lateral flexion in extension.

PROGRESSION

ROUTE 1
( L ) LF In N
( L ) LF In E

ROUTE 2
( R ) LF In N
( R ) LF In E
( L ) LF In E

Route 2 is less painful.
REGULAR STRETCH RESPONSES

Flexion is the primary movement and right lateral flexion with flexion is the primary combination.

PROGRESSION

ROUTE 1
( R ) LF In n
( R ) LF In F

ROUTE 2
( L ) LF In N
( L ) LF In F
( R ) LF In F

Route 2 is less painful.
IRREGULAR MOVEMENT RESPONSES

acute left buttock pain, irregular movement responses. Pain is produced in the C quadrant.
Extension is the primary movement and right lateral flexion in extension is the primary combination. So quadrant A is probably the best starting point because the movement can be directed away from the primary combination.

PROGRESSION

(L ) LF In F
(L ) LF In N
(L ) LF In E
(R ) LF In E

Muscle Energy Technique

“Muscle energy technique is a direct, non invasive manual therapy in which the therapist utilizes the barrier concept to position the patient’s body or part at their restrictive barrier followed by an isometric contraction & stretch to normalize joint dysfunction and increase ROM.”

HISTORY OF MET
FRED MITCHELL VIEW
In 1958 and then his son (mitchell et al 1979) have evolved a method in which the patient uses his/her muscles,on request from a precisely controlled position in a specific direction, against a distinctly executed counterforce. Some refinements were done by Karel lewit (1986) and Janda(1989)

SANDRA YALE VIEW
“MET is particularly effective in patients who have severe pain from acute somatic dysfunction such as those with a whiplash injury or a patient with severe muscle spasm from a fall . MET methods are also an excellent treatment modality for hospitalized or bedridden patients. They can be used in elder patients who may have severely restricted motion from arthritis or who have brittle osteoporotic bones”

PRINCIPLES
1) Law of Autogenic inhibition
“When a muscle is contracted isometrically this is followed by a period of relative hypotonicity, lasting for about 15 sec, during which a stretch of the tissues involved will be more easily achieved than before the contraction.”
2) Law of Reciprocal innervation
“During and following an isometric contraction of a muscle, its antagonist will be reciprocally inhibited, allowing tissues involved to be more easily strecthed.”



Law of Autogenic inhibition

Law of Reciprocal innervation

PROPRIOCEPTIVE MODEL OF DYSFUNCTION
If someone is bending forwards to lift something then abdominals are short of their normal resting length & extensors are stretched.
Korr (1947, 1975) says that because of their relaxed status, short of their resting length, there is silencing of the spindles.
However, due to a sudden demand for stability in this setting i.e. whatever was to be lifted unaccountably slips then a demand from a higher centers results in increased gamma gain reflexively.
As the muscle contracts rapidly to stabalise the alarm demands, the CNS would receive information that the muscle which is actually short of its neutral resting length was stretched.
This leads to inappropriate proprioceptor response muscles would have adopted a position of somatic dysfunction.
At the same time the stretched extensor muscles would rapidly shorten in order to stabalise the situation. In effect the two opposing sets of muscles would have adopted a stabalising posture to protect the threatened structures and in doing so would have become locked into positions of imbalance in relation to their normal function.

At this time any attempt to extend the area/joint would be strongly resisted by the tonically shortened flexor group. The individual would be locked into forward bending distorsion. Going further into flexion however would present no problems or pain.

NOCIOCEPTIVE MODEL (Van Buskirk’s)
Nocioceptors in a muscle are activated by minor trauma from a chemical,mechanical, thermal or other damaging stimuli.
Nocioceptive activation transmits impulses to other axons in the same nocioceptor as well as to the spinal cord.
peptide transmitters in the axon branches are released resulting in vasodilatation and the gathering of immune cells around the trauma site.

Direct mechanical restriction of the affected muscles derives from vasodilatation which, along with chemicals associated with injury – bradykinin, histamine, serotonin etc. – causes stimulation of local nocioceptors in muscle associated with the original trauma or those reflexively influences.
A new defensive muscular arrangement will develop which will cause imbalance and a shortening of the muscles involved.
After a matter of hours or days the abnormal joint positions which result from this defensive muscular activity become chronic as connective tissue reorganization involving tissue fibrocytes commences.
Connective tissue will be randomly oriented in the shortened muscle and less capable of handling stress.

HOW WOULD MET BE ABLE TO INFLUENCE THIS SITUATION?
In MET the skeletal muscles in the shortened area are initially stretched to the extent allowed by somatic dysfunction (to the barrier).
With the tissues held in this position the patient is instructed to contract the affected muscle voluntarily.
This isometric activation of muscle will stretch the internal connective tissues.
Voluntary activation of motor neurons to the same muscles also block transmission in spinal nocioceptive pathways.
Immediately following the isometric phase, passive extrinsic stretch is imposed, further lengthening the tissues towards normal easy neutral position.

HOW IS MET USED?
Concept of Ease and bind
Osteopathic pioneer H. V. Hoover (1969) describes ease as a state of equilibrium, or ‘neutral’, which the practitioner senses / or by having passive ‘listening’ contact in touch with the tissues being assessed.
Bind is opposite of ease and palpating the tissues surrounding, a joint which is taken towards the end of ROM – its resistance barrier
According to Goodridge – the barrier is not a pathological one but represents the first sign of resistance the place at which tissues require some degree of passive effort to move them.
We should try to note the moment at which we palpate the transition from one to the other, not to the extreme but where it begins.

Few questions which arise are:
Q. Why Patient’s voluntary contraction?
Ans. Repeated excitation of a pathway in CNS results gradually in easier transmission of nerve impulses through that pathway.this is brought about by a decrease in the synaptic resistance and is the basis of formation of correct habits and for learning.
Increase local blood flow and oxygenation

Q. Why lighter contractions ( i.e. 20% ) ?
Ans. It is considered that once a greater degree of strength than 25% of available force is used, recruitment is occurring of phasic muscle fibres, rather than the postural fibres which will have shortened and require stretching (Liebenson 1996).
It is far easier for the practitioner to control light contractions than strong ones, making MET a less arduous experience.
There is far less likelihood of provoking cramp, tissue damage or pain when light contractions rather than strong ones are used, making MET safer and gentler.
Karel Lewit (1999) have demonstrated that extremely light isometric contractions, utilizing breathing and eye movements alone, are often sufficient to produce PIR , and in this way to facilitate subsequent stretching.

Q. Why contraction is held for 7 to 10 seconds?
Ans. The contraction is held between 7 and 10 seconds as this time is necessary for the ‘load’ on the Golgi tendon organs to become active and to neurologically influence the intrafusal fibres of the muscle spindles,which inhibits muscle tone, so providing the opportunity for the area (muscle, joint) to be taken to a new resting length/resistance barrier with far less effort(Scariati 1991).

Q. What is the Role of breathing?
Ans. Muscle energy activity involves the holding of a breath during the contraction and the release of the breath as the new position or stretch is passively or actively adopted.
Cummings & Howell (1990) have looked at the influence of expiration on myofascial tension and have clearly demonstrated that there is a mechanical effect of respiration on resting myofascial tissue. Kisselkova, reported that non respiratory muscles receive input from the respiratory centres’
The abdominal muscles are assisted in their action during exhalation, especially against resistance
Movement into flexion of the lumbar and cervical spine is assisted by exhalation Movement into extension (i.e. straightening up from forward bending; bending backwards) of the lumbar and cervical spine is assisted by inhalation
Movement into extension of the thoracic spine is assisted by exhalation. Thoracic flexion is enhanced by inhalation
Rotation of the trunk in the seated position is enhanced by inhalation and inhibited by exhalation Neck traction (stretching) is easier during exhalation but lumbar traction (stretching) is eased by inhalation and retarded by exhalation.

Q How do we decide whether agonist or antagonist to be contracted?
Ans. ACUTE-RI ,CHRONIC-PIR

Q. Can the patient also participate in stretching?
Ans. Yes, it is preferred because it prevents a contraction of myotonic stretch reflex.
Patient errors during MET
Contraction is too hard (remedy: give specific guidelines, e.g. use only 20% of strength’, ).
Contraction is in the wrong direction (remedy: give simple but accurate instructions).
Contraction is not sustained for long enough (remedy: instruct the patient to hold the contraction until told to ease off, and give an idea ahead of time as to how long this will be).
The individual does not relax completely after the contraction (remedy: have them release and relax and then inhale and exhale once or twice, with the suggestion ‘now relax completely’).
Starting and/or finishing the contraction too hastily. There should be a slow build-up of force and a slow letting go; this is easily achieved if a rehearsal is carried out first to educate the patient into the methodology.

PRACTITIONER ERRORS IN APPLICATION OF MET :
1) Inaccurate control of position of joint or muscle in relation to the resistance barrier (remedy: have a clear image of what is required and apply it).
2) Inadequate counterforce to the contraction (remedy: meet and match the force in an isometric contraction; allow movement in an isotonic concentric contraction; and overcome the contraction in an isolytic manoeuvre).
3) Counterforce is applied in an inappropriate direction (remedy: ensure precise direction needed for best effect).
4) Moving to a new position too hastily after the contraction (there is usually more than 20 seconds of refractory muscle tone release during which time a new position can easily be adopted – haste is unnecessary and counterproductive).
5) Inadequate patient instruction is given (remedy: get the words right so that the patient can cooperate). Whenever force is applied by the patient in a particular direction, and when it is time to release that effort, the instruction must be to do so gradually.
6) The coinciding of the forces at the outset (patient and practitioner) as well as at release is important. The practitioner must be careful to use enough, but not too much, effort, and to ease off at the same time as the patient.
7) The practitioner fails to maintain the stretch position for a period of time which allows connective tissue to begin to lengthen (ideally 20–30 seconds, but certainly not just a few seconds)

GOALS OF MET
1.To lengthen tense muscle &fascia
2.To strengthen an asymmetrically weak muscle
3.To improve circulation ,respiration &N-M relationships.
4.To mobilize restricted joints.
5.To prepare joint for manipulation

INDICATIONS
a) Fibromyalgia
b) joint stiffness
c) stress and tension related problems
d) spinal & ribcage pain
e) chronic neck &back pain
f) migraine headaches
g) T-M joint pain
h) whiplash
i) sports injuries

CONTRAINDICATIONS
Acute inflammatory conditions
Malignancy
Aneurysm
Skin conditions
Recent major trauma
Infectious conditions
Disc herniation, fractures etc.

PHYSIOTHERAPY IN CONSTIPATION

Keeping in pace with the rapid growth and development in the medical field, physiotherapy is also widening its horizons. It has become an integral part of management of a wide variety of diseases. Its largest concern is related to the management of constipation in patients.

Constipation may be defined as infrequent motions (fewer than 3 times a week) or the need to strain at defecation. It has been reported to affect between 2 & 34% of adults. It is more prevalent in women and people over the age of 65 years.

ETIOLOGY & CLASSIFICATION:
The etiology for constipation is often multifactorial possible the sign of an underlying organic disease. It may also be attributable to lesions or structural abnormalities within the colon. These abnormalities may result in compression or narrowing of the intestines and rectum, causing difficulty in passing stools. Once disease and structural abnormalities are ruled out, constipation can be subdivided into:
a. NORMAL TRANSIT CONSTIPATION
i. Most prevalent subgroup of constipation
ii. In this, the stools move through the colon at a normal rate and stool frequency is normal yet patients believe that they are constipated because of a perceived difficulty with evacuation or the presence of hard stools.
b. DEFECATORY DISORDERS
i. Result from pelvic floor or anal sphincter dysfunction such as pelvic floor dyssynergia, spastic pelvic floor syndrome and anismus.
ii. In this, the external and sphincter contracts and tightens rather than relaxing and opening during defection.
iii. It is characterized by straining and incomplete bowel emptying
c. SLOW TRANSIT CONSTIPATION
i. Result from decreased neuromuscular function of the colon
ii. It is usually idiopathic
iii. Assorted with symptoms of an infrequent urge to defecate, bloating and abdominal pain discomfort, in addition to dry, hard stools.

DIAGNOSIS:
It is difficult because constipation is a symptom rather than a disease, and its diagnosis is based primarily on the patients’ perception of normal bowel function.
Rome II criteria is commonly used for the diagnosis. It includes:
a. Bowel frequency of < 3 times per week
b. Need to strain more than 25% of the time during defection
c. Lumpy or hard stools for more than 25% of bowel movements.
d. Sensation of incomplete evacuation or anorectal blockage for more than 25% of bowel movements.
e. Need for manual maneuvers (digital evacuation or support of the pelvic floor) to facilitate more than 25% of bowel movements

Two or more of these symptoms must be present for atleast 12 (consecutive or non-consecutive) weeks within the 12 month period.

COMPLICATIONS:Include prolapsed, pelvic floor muscle weakening, perineal descent.

PT MANAGEMENT OF CONSTIPATION
a. Lifestyle changes
i. Modify Diet (increase fiber and fluid intake)
ii. Exercise regularly
b. Educate the patient about toileting techniques to avoid straining during a bowel movement in order to decrease the risk of developing pudendal nerve dysfunction. These techniques are:
i. Leaning forward while sitting on the toiled with feet positioned on a step stool (this position decreases the anorectal angle, thus easing the evacuation of stools)
ii. Perform huffing (forced respiratory expiration) rather than straining during defecation (this technique activates the abdominal oblique muscles, which assist in the propulsion of stools)
c. Propulsive abdominal bowel massage to promote bowel mobility throughout the colon. It helps in increasing peristalsis in the gut. It is beneficial as its safe, non-invasive technique and can be performed by the patient independently.
i. Technique: Apply constant moderate pressure to the abdomen with 2 or 3 fingers. Small, clockwise circular movements are initiated at the right anterior superior iliac spine, which is located at the base of the ascending colon. The progression of the massage occurs cranially, up the ascending colon towards the base of the rib cage, where it meets the transverse colon. The circular movements are continued across the transverse colon toward the left upper quadrant of the abdomen and then down over the descending colon toward the left anterior superior iliac spine. This massage should be performed daily for 10 minutes.
d. Exercises to strengthen pelvic floor and sphincter muscles. Aerobic exercises also help in increasing gut transit.
e. Retraining pelvic floor muscle functioning during evacuation. This can be done by using Biofeedback. Patients can be trained to relax their External Anal Sphincter (EAS) during straining as well as to coordinate abdominal contractions to assist stool propulsion into the rectum.

Normal transit and slow transit constipation are managed well by directly modifications, exercises and abdominal massage, whereas defecatory disorders require retraining of pelvic floor muscle function.

3rd Model Test paper for MPT

Hey All.....Some more to test your brains :)

1. Coughing is usually considered a reflex controlled primarily by afferent stimulation of the
a. Trigeminal Nerve
b. Vagus Nerve
c. Phrenic Nerve
d. Glossopharyngeal Nerve

2. PEEP in chest care physiotherapy stands for
a. Peak Expiratory Exercise Programmes
b. Positive End Expiratory Pressure
c. Positive Endurance exercise for Pulmonary Performance
d. Peak Eletromyography and Electrocardiography of Pulmonary Performance

3. While treating patient in ward for chest care through coughing it should be ensured that
a. Sputum is not expectorated
b. The patient is in supine lying position
c. The diaphragmatic breathing not used
d. The bronchospasm is not induced

4. To determine the real leg length measurement is taken from
a. A.S.I.S to lateral malleolus on the same side
b. A.S.I.S to the great toe on the same side
c. A.S.I.S to the heel on the same side
d. A.S.I.S to the Medial malleolus of the leg

5. Ober test is used to test contracture of the
a. Rectus femoris
b. Glutens Medius
c. Piriformis
d. Illio-Tibia band

6. A 15 year old boy has pain over the Tibial Tubercle and clinically very prominent. The pain has been for four months and no history of injury and systemic illness. He most probably has
a. Osgood Schlatter’s disease
b. Rupture of Quadriceps Tendon
c. Fracture of Tibial Tubercle
d. Anterior Cruciate Ligament Instability

7. The Carpal tunnel located on the volar aspect of the wrist contains
a. Nine tendons and mediah nerve
b. Eleven tendons and ulnar nerve
c. Eight tendons and radial nerve
d. Seven tendons and median nerve

8. In electrocardiogram ‘QRS’ Complex represents
a. Atrial depolarization
b. Atrial jrepolarization and closure of semilunar valves
c. Venticular repolarization and opening of semilunar valves
d. Ventricular depolarization and it precedes ventricular systole

9. Conduction of nerve impulses is faster in Myelinated nerves because of
a. Uninterrupted flow of impulse
b. Salutatory conduction
c. Circular current flow
d. Quick reversal of current flow

10. The speed of conduction of impulse is a nerve fiber depends upon
a. The diameter
b. The strength of current
c. The muscle it supplies
d. Absence of myelin sheath

11. The elife of a Red Blood Cell is
a. 12 weeks
b. 12 days
c. 60 days
d. 120 days

12. Due to Paralysis or marked weakness of right side Zgluteus Meius the positive Trendelenburg sign results into
a. Dropping of Pelvis on the opposite side i.e. left side
b. Dropping of Pelvis on the same side i.e. right side
c. Flexion of Hip & Knee joint on the same side i.e. right side
d. Plantar flexion of right ankle to increase the length of right lower limb

13. The shortness of Tensor fasciae latae muscle causes
a. Adduction of the Hip
b. Extension of the Hip
c. Knocking (Genu Valgum) of the knee
d. Plantar flexion of the ankle

14. Thrombo angitis obliterans is also known
a. Trendelenburg’s disease
b. Thomas and Andy’s disease
c. Buerger’s disease
d. Philip’s disease

15. In Pseudo Gout the features include
a. Involvement of smaller joints and uric acid crystals
b. Involvement of large joints and calcium pyrophosphate crystals
c. Involvement of large joints and hyperuricemia
d. Involvement of large joints uric acid crystals

16. The mallet finger results from injury to
a. Abductor digiti minimi
b. Exgtensor carpi radialis longus
c. Extensor carpi ulnaris
d. Extensor tendon of the termincal phalanx of finger

17. Gower’s sign is seen in
a. Herpes Zoster
b. Sciatic Nerve Palsy
c. Duchemne muscular dystrophy
d. Marfan’s syndrome

18. Erb’s palsy is due to injury of
a. Head involving pre-central motor area
b. Pelvis involving Lumbo sacral plexus
c. Thorax involving Diaphragm
d. Upper roots of Brachial plexus involving C 5,6

19. The normal angle between vertical lines of Fermur and Tibia is
a. 7 Degrees
b. 12 Degrees
c. 1.5 Degrees
d. 0.5 Degrees

20. As per the WHO’s ICIDH classification, an impairment means
a. Pathological process due to microbes attacking a human body
b. Inability to perform activities of daily living with physiological dysfunction
c. Disabled, ambulatory on wheel chair with psychological impairment
d. Any loss or abnormality of psychological, physiological or anatomical structure or function

21. The head of femur receives its blood supply from
a. Medial and lateral femoral artery
b. Medial and lateral circumflex artery
c. Medial and lateral iliac artery
d. Medial and lateral gluteal artery

22. Piriformis syndrome involves
a. Gluteal nerve
b. Femoral nerve
c. Sciatic nerve
d. Obturator nerve

23. The thermal conductivity in the following tissues is higher
a. Muscles
b. Skin
c. Ligaments
d. Fat

24. To reduce spasticity the following modality is more suitable
a. Cryotherapy
b. Ultrasonic
c. T.E.N.S
d. Hot packs

25. In normal erect posture the Lumbo sacral angle is about
a. 5 Degree
b. 2.5 Degree
c. 45 Degree
d. 30 Degree

2nd Model Test Paper for MPT Preperation

Hi Folks....
There is another ser of 25 questions specially for you all....

1. The valsalva manoeuvre
a. Is an attempt to forcibly exhale with the glottis, nose and mouth closed
b. Increases the intra-thoracic pressure
c. Increases the intra-discal pressure
d. All of the above

2. Unilateral neglect is characterized by
a. The inability to register and to integrate stimuli and perceptions from one side of the environment
b. Patients usually ignore stimuli occurring on the side of neglect
c. Both (A) & (B)
d. None of the above

3. Monteggia fracture is described as
a. Fracture and dislocation of the lower 1/3 of the ulna
b. Fracture of the upper 1/3 of the ulna associated with dislocation of the head of radius (with or without a fracture)
c. Fracture of the upper 1/3 of the radius with dislocation of the ulna
d. Fracture of the lower 1/3 of the humerus with dislocation

4. A skin autograft is best described as
a. A graft where the skin is taken from the patient himself/herself
b. A graft where the skin is taken from another person or a donor
c. A graft where the skin is taken from another species
d. All of the above

5. Which of the following statements describes a phantom limb
a. A limb that is gangrenous
b. A limb that has lost all sensation
c. A limb that no longer exists but the patient complains of excruciating pain from its fingers/toes
d. All of the above

6. Which of the following testing procedures is used to quantify muscle soasticity
a. Pendulum test and the H-reflex
b. MMT
c. Cable tensiometers
d. Functional ambulation profile

7. On a chest X-ray the SILHOUETTE sign presents as
a. The two separate structures adjacent to each other are not identificable because of the lack of contrast in densities
b. Paralysis of diaphragm over shadows the lungs
c. Enlargement of Cardiac field in transverse direction
d. A sharp contrast between the two adjacent structures with pathological changes

8. The close packed position of Hip Joint is
a. Full Flexion, External rotation and Abduction
b. Full Flexion, Internal rotation and Abduction
c. Full Extension, Internal rotation and Abduction
d. Full Extension, External rotation and Abduction

9. The specific gravity of a human body is
a. 1.995
b. 0.095
c. 0.95
d. 9.05

10. Fluido-therapy is
a. Dry heat modality
b. Fluid immersion therapy
c. Application of analgesic fluid
d. Application of radiation through fluid

11. To calculate %age TBSA (according to the rule of nines) Left lower extremity is given weightage of
a. 9%
b. 9.9%
c. 27%
d. 18%

12. In De Quervain’s syndrome the following tendons are inflamed
a. Extensor pollicis longus and Extensor pollicis brevis
b. Extensor carpi radialis longus and Opponens
c. Extensor pollicis brevis and Abductor pollicis longus
d. Abductor pollicis longus and Extensor carpi radialis brevis

13. The SAID principle stands for
a. Specific Adaptations to Imposed Demands
b. Severe and Incurable Disability
c. Shock After Infusion of Drugs
d. Specific Amputation for Impairment and Disability

14. The three types of polio virus isolated are
a. Brunhilde, Mcmurray and Newon
b. Leon, Mcburney and Vlodik
c. Brunhilde, Lansing and Leon
d. Mchilde, Salk and Newon

15. The rate of pin rolling tremors in Parkinson’s disease is
a. 1-2 times per sec
b. 20-30 times per sec
c. 16 times per sec
d. 6-8 times per sec

16. The normal A-VpO2 difference is
a. 14.5 mm Hg
b. 95 mm Hg
c. 9.5 mm Hg
d. 55 mm Hg

17. The Bohr’s effect causes
a. Increase of hemoglobin level
b. Loading of CO2 and unloading of O2 in blood
c. Loading of O2 and unloading of Co2 in blood
d. Loading of CO2 and unloading of NO2 in blood

18. The resting membrane potential of skeletal muscle fibre is
a. -90 mv
b. -0.9 mv
c. -0.09 mv
d. -0.009 mv

19. The commonest site of Myositis Ossificans Traumatica is
a. Brachialis
b. Extensor carpi radialis longus
c. Triceps Brachii
d. Brachioradialis

20. The clinical Triad of Reiter’s syndrome consists of
a. Hepatitis, arthiritis and otitis media
b. Hepatitis, arthiritis and conjunctivitis
c. Urethritis, conjunctivitis and crystal formation
d. Urethritis, arthritis and conjunctivitis

21. The ideal length of stump amputated below knee should be about
a. 5 cm
b. 7 cm
c. 30 cm
d. 14 cm

22. The Dielectric constant of tissues with high water content
a. Is less than the Fatty tissues
b. Is less than the bonny tissues
c. Is less than the skin
d. Is more than the tissue with low water content

23. The Dielectric constant of water is
a. 8.1
b. 81.1
c. 18.1
d. 1.08

24. The cavitation effect of ultrasound application to human body is
a. Micro-massage
b. Rise in local temperature
c. Analgesic effect on nerves
d. Gas bubble in tissues

25. The cross section of a muscle is equal to
a. Width X Thickness
b. Length X Width
c. Length X ½ Thickness
d. 2 (Thickness) + 2 (Width)

1st Model Test Paper for MPT Entrance Examinations

Hello Folks.....
I am posting a set of 25 MCQs as a model test paper for MPT entrance examinations. To get the solutions please reply to the blog with your email-id so that I can send you the answers.
Remeber friends, this is just the beginning of the set of questions.....
Each question has 4 choices (a,b,c,d)

1. In absence of Deltoid, trick abduction movement of shoulder joint is performed by:
a. Spurious contraction of pectoralis major
b. Deceptive action performed by the favorably placed muscles around shoulder joint.
c. Tenodesis action
d. Serratus anterior and Trapezius

2. Nerve root value of hip abductors and extensors is:
a. L3, 4
b. S2, S3
c. L4,5, S1
d. T12, L1, 2

3. Co-ordination is space, rhythm and approach is disturbed in the lesion of:
a. Pyramidal tract
b. Cerebellum
c. Mid brain
d. Spinal Cord

4. Clawing of the hand results due to the paralysis of
a. Flexor digitorum sublimis and profundus
b. Thenar and hypothenar group of muscles
c. Extensor groups of muscles
d. Intrinsic group of muscles

5. Which of the following are indicative of posterior column disturbances?
a. Ataxia, ataxic gait, ramberg sign, and athtosis
b. Ataxia, athetosis, asthenia and dystonia
c. Dystonia, dysmetria, dys synergia and dysdiadochokinosia
d. Ataxia and Romberg sign

6. Which one of the following, a person must have innervated for active triceps
a. C5
b. C6
c. C7
d. C8

7. If a patient has a diagnosis of C5 quadriplegia which of the following group of muscles would he have active use of?
a. Pectoralis major, biceps and deltoids
b. Biceps, supinator and deltoids
c. Serratus anterior, latissimus dorsi and wrist extensors
d. Bicep, deltoids and serratus anterior

8. Strengthening excercises during the acute inflammatory stage of the arthritic joint should be
a. Encouraged
b. Reduced
c. Avoided
d. The same as in the sub acute and chronic stages

9. Approximately after how many weeks, generally, the ptient is allowed to resume normal activities following tendon repair
a. 8 weeks
b. 10 weeks
c. 12 weeks
d. 16 weeks

10. The short head of the Biceps Brachii has a common origin with the
a. Long head of biceps brachii
b. Coraco brachialis
c. Brachialis
d. Long head of triceps brachii

11. A child is said to be severely mentally retarded when IQ is in the range of
a. 35-49
b. Below 20
c. 20-34
d. 50-70

12. The voluntary opening terminal device of an upper extremity Prosthesis is activated by
a. Humeral extension
b. Shoulder gridle protraction
c. Humeral Flexion
d. Scapular adduction

13. The best splint to correct claw hand is Median and ulnar palsy is the
a. Cock-up
b. Spring wire suspension
c. Knuckle bender
d. Pan cake

14. A patient with a complete musculocutaneous nerve injury would have no function of the
a. Triceps brachii muscle
b. Pronator teres muscle
c. Biceps brachii muscle
d. Deltoid muscle

15. The MAIN purpose of passive range of motion exercises is to:
a. Strengthen muscles
b. Prevent contractures
c. Increase coordination
d. Provide proprioceptive input

16. Contraction of the diaphragm
a. Draws the central tendon of the diaphragm downwards
b. Increases the volume and increases the pressure within the thoracic cavity
c. Decreases the volume and decreases the pressure within the abdominal cavity
d. All of the above

17. The phalen’s test:
a. A test designed to determine the presence of laternal epicondylitis (tennis elbow)
b. A test designed to determine the presence of peripheral neuropathy
c. A test designed to determine the presence of an impingement syndrome
d. A test designed to determine cvarpal tunnel syndrome

18. Which of the following best describes an action potential
a. A brief regenerative electrical potential that propogates along a single axon or muscle fibre
b. It is an all-or-none phenoemenon
c. Whenever the stimulus is at or above threshold, the action potential generated has a constant size and configuration
d. All of the above

19. Cycles of gradual increase in rate and depth of respiration with apenic pauses between cycles, describes which of the following
a. Tachypnea
b. Orthopnea
c. Bradpynea
d. Cheyne-Stokes respiration

20. The Barthel’s Index is used to measure one of the following
a. Muscle strength
b. Sensory-motor abilities
c. Functional abilities
d. All of the above

21. During crutch walking using a four point gait, which of the following statements is true?
a. One crutch is advanced followed by the advancement of the opposite lower extremity
b. Only one leg or crutch is off the floor at a time, leaving three points for support
c. This is a stable and safe gait and is thus useful in patients who are able to move their lower extremities alternately but who have poor balance or are not able to bear full weight bilaterally without the support of crutches
d. All of the above

22. The wavelength range of Short Wave Diathermy is
a. 300 X 109 to 30 X 109
b. 1 X 109 to 1.5 X 109
c. 30 X 109 to 3 X 109
d. All of the above

23. The performance of which of the following muscles is affected by forearm position
a. Brachialis
b. Biceps Brachii
c. Brachioradialis
d. Only B & C

24. Which of the following statements describes diastasis of rectus abdominis
a. Widening of the linea alba
b. Condition associated with pregnancy
c. The presence can be palpated as a hollow between the superficial rectus abdominus muscle
d. All of the above

25. The gate control theory explains
a. Theory of pain
b. Theory of spasm
c. Theory of stiffness
d. Theory of flexibility