29/05/2013

Wo rld Massage C onference Presents:

Clinical Orthopedic
Or thopedic Manual
Manual Therapy
T h erapy
Com bining (COMT)
Soft
T i ssue Manipulation
Joe Muscolino DC
wi th Stretching and
Joi nt Mobilization
with Joe Mu scolino

Table of contents

What is COMT ?

Assessment

COMT treatment techniques

Hydrotherapy

Soft tissue manipulation

Stretching

Joint mobilization

What is COMT?

What does “clinical” mean?

What does “orthopedic” mean?

Why “manual therapy”?

1
 29/05/2013

Alternative?
What are the demographics?

Clients who want a specific musculoskeletal complaint

remedied:

80%... 60%...

Musculoskeletal niche

Muscle doctor?

PT /DC/DO/Fitness trainer

T he lack of attention in Western medicine to the

muscular system (and all soft tissues in general) opens
the niche to MTs to become the “go to” therapists for
muscular/soft tissue conditions.

This webinar – BIG picture

Many massage therapists limit their effectiveness by:

1. not working assertively enough to effect changes in

the client’s body.

2. ignoring intrinsic joint tissues.

T his webinar is about putting together fundamental
treatment approaches into the treatment session to be
clinically effective.

2
 29/05/2013

Technique seminars

T his is not a branded technique seminar that claims to
miraculously cure every condition with which the client
presents.

This webinar…

T his webinar is about using critical thinking skills to
creatively apply fundamentally sound orthopedic
treatment approaches for your clients’ musculoskeletal
conditions.

Let’s start with assessment…

Assessment

“Never treat without a diagnosis.”

“Never treat without an assessment.”

An accurate assessment gives you a target for

treatment.

3
 29/05/2013

How do we assess?

Verbal history

Physical exam (assessment tests)

Range of motion

Special orthopedic assessment tests

Palpation (static and motion)

Response to treatment

Verbal history

Where does it hurt?

When did it begin?

Was there a precipitating trauma?

What is the quality of the pain?

What is the severity of the pain (0 – 10 scale)

Does it refer?

Verbal history cont’d

Have you had this before?

Is it getting better or worse?

What makes it better/worse?

What are your typical postures/activities

What do you think is/are the cause(s)?

What is your goal?

4
 29/05/2013

Nature of the physical exam

“Stress and assess”

An assessment test, by definition, places a stress on

the client… on a specific structure/tissue

Response to examination

A healthy tissue should be able to receive this stress
without pain (or other symptoms)…

An unhealthy tissue responds with pain (or other

symptoms)

Because the physical exam stresses the client’s body, it

will likely aggravate the client’s condition.

Physical exam…

Range of motion – challenges motion

T ight antagonists?

Fascial adhesions?

Healthy joint surfaces?

Special orthopedic assessment tests

Assess specific conditions

Palpation…

5
 29/05/2013

Muscle palpation
Understand – critically think! Apply guidelines…

Know the attachments to know where to place your

fingers.

Know actions

Know the action(s) to make it engage.

T he goal to locating the target muscle is to try to create

an isolated contraction of it. This way, it is the only hard
tissue amongst a sea of soft tissues.

For this, we need to know the actions of the target

muscle, as well as the adjacent muscles.

Muscle palpation example

6
 29/05/2013

When do we assess?

Always… whenever we are observing or touching the
client…

A “formal” assessment is usually done at the beginning

of the first session.

Might this be skipped?

In successive visits, it is usually more efficient to either

do a very brief re-assessment and then begin
treatment, or to assess as the treatment is
administered.

Formulating an assessment

Cookbook vs. critical thinking

What is necessary to critically think?

Fundamental core basis of anatomy – physiology –

pathophysiology – assessment – treatment.

Critical thinking allows for creative application.

Assessment example

Active ROM

Passive ROM

Manual resistance

What does each test stress and therefore assess?

7
 29/05/2013

SLR assessment test

Treatment planning

Frequency:

“Wow! T his client comes in EVERY week! ”

“T his client only comes in ONCE a week?!”

Rehabilitation strategy…

PT /DC/fitness training, etc.

We are fighting chronicity, not severity… muscle

memory patterns, adhesions

Effect of frequency

8
 29/05/2013

COMT treatment techniques

HYDROT HERAPY

SOFT T ISSUE MANIPULAT ION

ST RET CHING

JOINT MOBILIZAT ION

Hydrotherapy

Heat / ice

Look at the mechanism(s)

Heat – vasodilation & relaxation

Ice – vasoconstriction & anesthetic

So, when do we apply ice…? heat…?

Soft tissue manipulation

Body mechanics for deep pressure…

Use your core body weight (table low)

Use larger muscles

Work perpendicular to contour

Brace/double support your contact

9
 29/05/2013

Body mechanics

Stretching

Stretching is essentially a mechanical process

Make a soft tissue longer

For a muscle, how do we figure out how to stretch it?

Multiplane stretching

10
 29/05/2013

Advanced stretching
techniques

Pin and stretch

Neural inhibition techniques

Contract relax (CR)

PIR – postisometric relaxation

PNF – proprioceptive neuromuscular facilitation

Agonist contract

(basis of active isolated stretching [AIS])

Pin and stretch

Pin along the muscle and then stretch the muscle
longer.

Why?

Pin and stretch – piriformis

11
 29/05/2013

CR stretching mechanism

Stated basis is the Golgi tendon organ (GT O) reflex

When a muscle contracts, it pulls on its tendons,
stretching the GT Os, resulting in inhibition/relaxation of
the muscle (and its synergists).

We take a dvanta ge of t his neural inhibition to stretch

the muscle furthe r than we would othe rwise ha ve be en
able to.

CR stretching protocol

T herapists brings the target tissue to tension

Client (isometrically) contracts against the resistance of
the therapist

T herapist then stretches the client further

CR stretching protocol cont’d

T ypically 3-4 repetitions

Contracts for approx. 5-8 seconds

Only approx. 25-50% contraction strength needed

Breathing protocol…

12
 29/05/2013

First, body mechanics

Core Pectoralis

CR body mechanics cont’d

Forearm (deltoid) Alternative stabilization

Beginning CR technique
T issue brought to tension

13
 29/05/2013

CR first repetition
Resistance Stretch

CR second repetition
Resistance Stretch

CR third repetition
Resistance Stretch

14
 29/05/2013

AC stretching mechanism

Basis is the reciprocal inhibition (RI) reflex

When a muscle contracts, the antagonist musculature
on the “other side” of the joint must lengthen.

T herefore whenever agonist/mover musculature

contracts, the antagonist musculature is (reciprocally)
inhibited/relaxed.

We take advantage of this neural inhibition to stretch

the muscle further than we would otherwise have been
able to.

AC stretching protocol

Client actively moves into the stretch (our target
musculature is the antagonist of the motion)

T herapist stretches the client further

T herapist brings the client back to starting position

AC stretching protocol cont’d

T ypically 8-10 repetitions

Entire repetition lasts approx. 5-8 seconds

Breathing protocol…

15
 29/05/2013

Again, body mechanics

Core Pectoralis

AC technique
T herapist augments
Client actively moves stretch

AC technique cont’d
Client returned to starting position

16
 29/05/2013

CRAC stretching

Perform CR and AC sequentially

Mechanism(s)…

Breathing protocol…

Again, body mechanics

Core Pectoralis

CRAC technique
Resistance Client actively moves

17
 29/05/2013

CRAC technique cont’d

Augment stretch Return to starting position

Chicken and egg

Effective musculo/skeletal treatment requires treatment of
the:

Muscles

Joints

Muscle and joint

MTs all too often ignore the joints.

For this reason, we need to approach our treatment
plan with multiple techniques that are directed toward
all soft tissues, including the intrinsic soft tissues of the
joint.

18
 29/05/2013

Joint mobilization

Joint mobilization is essentially a specific form of pin
and stretch

But instead of pinning along a muscle, we pin one

bone, and then move the adjacent bone relative to it.

T his stretches the intrinsic tissues that cross the joint

musculature, ligaments, joint capsules

Joint mobilization cont’d

Note: Joint mobilization NEVER involves a fast thrust!

Note: Check with your state or other regulatory body to
make sure that joint mobilization is within your scope.

Motion palpation assessment

Assessment for joint mobilization is motion palpation.

Motion palpation is palpating the motion of a joint.

Motion palpation of the spine is the only way to find a

segmental hypomobility.

In effect, this assessment technique is also the

treatment technique of joint mobilization.

19
 29/05/2013

Motion palpation…
Joint mobilization
Place pin Bring to tension

Motion palpate / mobilize

Add motion / mobilize

Contact
Index finger contact Finger pads contact

20
 29/05/2013

Joint mobilization of the

lumbar spine

Joint mobilization
contraindications

Contraindications for joint mobilization of the spine are
effectively the same as for stretching:

anything that would cause nerve impingement

Pathologic disc

Marked/severe osteoarthritic bone spurs

Order of techniques

T here is no right or wrong…

A good guideline/default is:

Soft tissue manipulation

Heat

Stretching

Joint mobilization

Modifications…

21
 29/05/2013

Photo credits

COMT Certification
Workshops:

COMT: Neck

COMT: Low Back and Pelvis

COMT: Upper Extremity

COMT: Lower Extremity

COMT: Spinal Joint Mobilization

Distance learning modules

www.learnmuscles.com

Contact Information:

The Art and Science of Kinesiology

joseph.e.muscolino@gmail.com
www.learnmuscles.com

22