OMT Evaluation

Dr. Sidra Sohail

Learning Objectives
At the end of this lecture, students will be able to describe:
▪ Orthopedic manual therapy
▪ Goals of OMT Evaluation
▪ Elements of OMT Evaluation
 Orthopedic Manual Physical Therapy
▪ Manual therapy is a 'hands-on' treatment provided by an orthopedic manual
physical therapist to decrease pain and improve the motion of the targeted
neuromusculoskeletal structures inside a patient's body.
Goals of the OMT Evaluation
The OMT evaluation is directed toward three goals:
▪ Physical diagnosis
To establish a physical, or biomechanical, diagnosis.
▪ Indications and contraindications
To identify indications and contraindications to treatment.
▪ Measuring progress
To establish a baseline for measuring progress.
Diagnosis:
Determination of the nature of a cause of a disease.
▪ Medical diagnosis:
Diagnosis based on information from sources such as findings from a physical
examination, interview with the patient or family or both, medical history of
the patient and family, and clinical findings as reported by laboratory tests and
radiologic studies.
▪ Clinical diagnosis:
Diagnosis based on signs, symptoms, and laboratory findings during life.
▪ Differential diagnosis:
The determination of which one of several diseases may be producing the
symptoms.
▪ Radiological diagnosis
Physical diagnosis
▪ Diagnosis based on information obtained by inspection, palpation,
percussion, and auscultation.
▪ Diagnosis based on a physical examination of a patient.
▪ Refinement of the medical diagnosis and the functional status.
▪ The physical diagnosis is based on a model of somatic dysfunction that
assumes a highly interdependent relationship between musculoskeletal
symptoms and signs.
▪ In the presence of somatic dysfunction, there is a correlation between the
patient's musculoskeletal signs and the production, increase, or alleviation of
symptoms during a relevant examination procedure.
▪ Musculoskeletal conditions that respond well to treatment by manual therapy
typically present with a clear relationship between signs and symptoms.
▪ An OMT evaluation that shows no correlation between signs and symptoms:
▪ Usually indicates that the patient's problem originates from outside of the
musculoskeletal system
▪ So that mechanical forms of treatment such as manual therapy are less
likely to help.
▪ The manual therapist confirms the initial physical diagnosis of somatic
dysfunction with a low-risk trial treatment as an additional evaluation
procedure.
▪ For example, traction is the most common trial treatment for a joint
hypomobility.
▪ If the trial treatment does not alleviate symptoms or if symptoms are
worsened, further evaluation is necessary and a different trial treatment is
tested.
Indications & Contraindications
Indications
Indications for treatment by manual therapy are based more on the
physical diagnosis than on the medical diagnosis.
▪Restricted joint play (hypomobility)
▪An abnormal end-feel
▪are the most important criteria for deciding if mobilization is indicated.
▪ Grade III stretch mobilization is indicated when a movement restriction
(hypomobility) has an abnormal end-feel and appears related to the
patient's symptoms.
▪ Hypomobility presenting with a normal end-feel and no symptoms ,is not
considered pathological, so not treated.
➢ In such cases, the movement restriction is either due to a congenital anatomical
variation, or the symptoms in that area are referred from another structure.
▪ In patients with hypomobility due to muscle spasm in the absence of tissue
shortening, relaxation mobilizations in the Grade I - II range are generally
effective.
Contraindications for Mobilization
◦ Inflammatory arthritis ◦ Neurological involvement
◦ Malignancy ◦ Bone fracture
◦ Tuberculosis ◦ Congenital bone deformities
◦ Osteoporosis ◦ Vascular disorders
◦ Ligamentous rupture ◦ Joint effusion
◦ Herniated disks with nerve ◦ May use I & II mobilizations
compression to relieve pain
◦ Bone disease
 Specific contraindications to Grade III
stretch mobilization
techniques include:
▪ decreased joint play with a hard, nonelastic end-feel in a hypomobile
movement direction
▪ increased joint play with a very soft, elastic end-feel in a hypermobile
movement direction
▪ pain and protective muscle spasm during mobilization
▪ positive screening tests, for example, pain induced by compression tests
Measuring Progress
▪ Changes in a patient's condition are assessed by monitoring.
▪ Changes in one or more dominant symptoms and comparing these changes
with routine screening tests and the patient's dominant signs.
▪ Symptoms in the spine may include pain, changes in sensation, a feeling of
greater strength or ease of motion, or reduced fatigue.
▪ Physical signs of spinal origin may include altered joint play, range of
movement, reflexes, or changes in muscle performance.
▪ Periodic reassessment of the patient's chief complaints and dominant physical
signs during a treatment session guides treatment progression.
▪ If reassessment reveals normalization of function (e.g., mobility) along with
decreased symptoms, then treatment may continue as before or progress in
intensity.
▪ When reassessment during a treatment session indicates that function is not
normalizing or that symptoms are not decreasing, be alert to the need for
further evaluation to determine a
▪ more appropriate technique,
▪ positioning,
▪ direction of force,
▪ or treatment intensity
Elements of the OMT Evaluation
Diagnosis & trial treatment
▪ Through the physical examination the therapist correlates the patient's signs
with their symptoms.
▪ A relationship between musculoskeletal signs and symptoms suggests a
mechanical component to a problem that should respond well to treatment
by manual therapy.
▪For instance, before treating a patient who is unable to flex the lumbar
spine, you must first determine if the limitation is due to
▪pain (e.g., lumbar radiculopathy),
▪hypomobility e.g., soft tissue contracture,
▪intraarticular swelling,
▪disc herniation,
▪nerve root adhesion,
▪weakness (e.g., peripheral neuropathy, primary muscle disease),
▪or a combination of those disorders.
Differential Diagnosis for OMT
▪ The OMT practitioner must make three major differential diagnostic decisions
when evaluating spinal somatic dysfunction:
▪ Determine whether the somatic dysfunction is primarily in the segment (e.g.,
the "anatomical joint") or associated soft tissues, including neural structures .
▪ Determine if joint hypo- or hyper-mobility is present, and whether it is
pathological (i.e., associated with an abnormal end-feel.
▪ Determine whether treatment should be directed toward pain control or
biomechanical dysfunction.
Reference
▪ Manual Mobilization of the Joints-The Spine Vol 2 (4th Edition) by Freddy M.
Kaltenborn.