Medical and Biological Sciences XXVI/2 - Collegium Medicum ...

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26 Magdalena Hagner-Derengowska et. al. odpowiednio 0,5 stopnia i 0,5 milimetra. To prowadzi do wniosku że manualne testowanie pierwszego oporu mięśnia podczas biernego ruchu wykonywane przez doświadczonego terapeutę cechuje się bardzo dobrą powtarzalnością. Key words: muscle movement resistance Słowa kluczowe: opór mięśni First resistance in passive muscle lengthening, so called tissue resistance, is very important in physiotherapy used nowadays. Possibility to find this moment in muscle stretching is a main important skill of every therapist dealing with musculoskeletal disorders [1,2,3]. In examination of muscle, reaching this point allows assessing its tension and flexibility [1,2,4]. In tension test of nerves this moment of first resistance allows therapist to perform such examination and avoid patient’s pain and nerve irritation [1,5]. From that point in range of movement therapist try to sense an ‘end feel’ and differentiate it [1,2,3,5,6] . Also in examination of joints, a point of first tissue resistance is a reference point in procedure of joint play testing, even though it concerns rather joint capsule and translatoric movements, such as glides and traction than muscle itself and physiological movement [1,7]. Nevertheless, skill of sensing this moment remains the same. That skill concerning more superficial tissues is also widely used for diagnosis in therapeutic methods such as Kinesiology Taping or different form of fascia assessment and therapy [8,9]. Exact feeling of first resistance is even more important in therapeutic than in testing procedures. There are many techniques using point of first resistance as a reference point, including muscles, peripheral nerves, joint capsule or other soft tissue, such as fascia [4,8,9,10,11,12]. Moreover, it is often stated that physiological reaction and therapeutic effects could be different depending on force used to lengthening this tissues in relation to point of first mechanical resistance, i.e. length and force is lower, equal or higher than that point [4,8]. In Post Isometric Relaxation of muscles (PIR), the isometric voluntary muscle contraction has to be done specifically at the moment of tissue resistance – first resistance in passive movement which lengthens the muscle. On one hand, precise localization allows a possibility of muscle relaxation, on the other hand it does not cause pain or other unwanted effects. Performing these techniques on greater stretch of the muscle than point of first resistance is considered as mistake [4,8,10]. In joint capsule mobilization, the moment of first resistance for passive movement is a dividing point between first grade mobilization, used for relaxation, joint surface nutrition and analgesic action, and third grade mobilization, which is used in joint capsule stretching [1,3,7,11]. In these techniques, like in many others, feeling of first resistance is of great importance to achieve desired results. In muscles, described above point of first resistance is related mainly with myofibrils, contractile part of muscle belly, namely with their initial, resting tension, called tonus [13,14]. Sensing that moment during passive muscle stretching connected with standard linear or angular measurement techniques could be then considered as examination of muscle tonus. For this application, even more than for described earlier, accuracy and repeatability between tests and between investigators are required. Only when these conditions are satisfied, manual testing of muscle first resistance could be used for measurement. The goal of this paper is to determine the repeatability of calf muscle first stretch resistance assessment (the tissue resistance) of test results obtained by the same therapist - intrarater repeatability. MATERIALS The study included 34 tests conducted on 17 participants, both men and women, patients of the Spa Clinic “Pod Tężniami” named after John Paul II in Ciechocinek. Mean age of this group was 35.6 (±8.5). The group consisted of 6 men and 11 women. All participants had signs of shortening triceps surae muscles in clinical examination and for all of them the post isometric relaxation technique for that muscle were used as a therapy of choice. In any case conducted measurement did not disturb or affect treatment based on clinical reasoning. The exclusion criteria for this study were as follows: • Injury of the ankle joint • Degeneration of the ankle joint grade III or IV • Occurring pain during ankle flexion • Limitation of knee extension • Straight Leg Raise test below 30 degrees • Lumbar pain with radiation below the knee • Lack of cooperation with therapist • Neurological diseases affecting muscle tension Existed trigger points (unless in acute phase) were not considered as contraindication. In general, all
Intrarater repeatability of manual testing of first muscle movement resistance 27 participants had increased muscle tension, i.e. functional problem, rather than structural contraction. METHOD The test was conducted using three-dimensional movement measuring system based on active ultrasound markers, ZEBRIS, manufactured in Germany by ZEBRIS Medical GmbH. In that case system consists of ZEBRIS CMS-HS main unit, measuring unit (MU), and set of four single ultrasound markers (transmitter). The main unit collects the signal from the measurement unit and provides control and coordination between single ultrasound markers, initializing signal sent by them. Main unit collects and initially processes acquired data in real time measurement. The measuring unit consists of three single receivers (microphones), fixed on a solid frame in established position to each other. Each microphone calculates simultaneously distance from the ultrasound marker or markers. This allows, when using triangulation rules, to define coordinates of each transmitter in three dimensional coordinate system referred to measuring unit. Calibration allows determining the MU towards the frontal, sagittal and transversal plane [15]. Single ultrasound markers are small transmitters, which could be placed on patients’ skin using adhesive tape or Velcro strips. The frequency of signal emitting is set in software used and can be changed depending on measurement requirements and equipment capabilities. Placement of transmitters can be dictated by a software and protocol used, or freely chosen by user. The precision of marker localization in optimal condition can be very high, and reaches values below 0.14 mm for linear and 0.16 degrees for angular movement [16]. In this study WinData (ZEBRIS Medical GmbH, Germany) software were used. This software has no rigid protocols of measurement, and provides possibility of construction complete and individual measurement protocols which fits best to the specific requirements of a particular study [17]. In order to assess manual testing of triceps surae (TS) first mechanical resistance repeatability, authors measured angular position of the ankle and calf muscle length at the moment when the therapist felt that resistance. To achieve this, the single markers were placed on: • Lateral femoral condyle • Posterior part of calcaneal tuberosity at the attachment of the Achilles tendon • Above lateral ankle, at the axis of flexion/extension movement • Lateral side of 5-th metatarsal bone base Based on this markers placement, following parameters were calculated: 1. Ankle flexion, described as Angle between vector of the fibula, connecting marker on lateral femoral condyle and lateral ankle, and line built of markers on lateral ankle and 5-th metatarsal bone. 2. Length of the Triceps Surae muscle, and actual length of lateral head of gastrocnemius muscle. That was calculated as a distance between a marker placed on insertion and origin of that muscle, i.e. on lateral femoral condyle and on calcaneal tuberosity. The frequency of signal transmission for each marker was 20 Hz. The test was executed by a skilled and experienced in manual therapy therapist. Patient was lying supine on a couch, in comfortable position, with both legs extended. After placing markers on the right positions, the therapist asked the patient to relax and try not to make any movement. Then the therapist made three attempts to flex patient’s ankle to dorsal flexion till he felt first mechanical resistance of stretched Triceps Surae muscle. The therapist was asked to stop for about two three to five seconds after reaching this ‘destination point’. Spatial position of all four markers was recorded from the beginning to the end of the test. The knee of the patient was still fixed in extension. The therapist performing manual testing was not allowed to see the monitor screen with graphical exposition of measured angular parameters till the test was over. Obtained data were then analyzed using standard statistical tools, such as mean, standard deviation, relative values and standard error of mean in Microsoft Office software. RESULTS For every test there were three values of angular position of foot and lower limb collected, each of every trial. Based on these results, Standard Deviation
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