Motion End-feel in Clinical Assessment

I’ve recently been reflecting on the clinical relevance of evaluating end-fee in clinical practice. The issue arose from  a conversation about interpreting patient response to manual therapy and whether “useful clinical change” was being achieved. Changing end-feel is certainly part of the manual therapists armory and needs to be considered in conjunction with range of motion as a measure of effectiveness. However in situations of established degenerative change the clinical objective may be to improve tolerance of static positions (typically lying in spinal conditions) and in these cases improving end-feel is often the key criteria in reducing symptoms without tangible range changes.

Conversely, failure to alter end- feel is a poor prognostic indicator and one where the clinician must be vigilant.

Knowing when not to treat is also a skill we must embrace.

I’ve included a refresher summary below of the issues associated with end-feel in spinal examination.

Different sensations of movement barriers can be perceived according to the tissues limiting motion, the anatomical region, and pathological change.  Cyriax describe a number of characteristic End-feels

1. Bone to bone
2. Spasm
3. Capsular feel
4. Springy block
5. Tissue approximation
6. Empty feel

Kaltenborn summary of end-feel

1. Normal soft end-feel due to soft tissue approximation
2. Normal firm end-feel due to capsular ligamentous stretching
3. Normal hard end-feel (bone to bone)

In pathological states the variations may be:

1. A firm less elastic feel (indicative of scar tissue or shortened connective tissue)
2. An elastic less soft end-feel (indicative of increased muscle tone)
3. An empty end-feel (patient limits movement prior to resistance)

(This is indicative of inflammation, serious pathology or fear avoidance behaviour)

ACCESSORY MOVEMENT

In order to allow physiological movement joint surfaces undergo combinations of rotation and translation.  These characteristics are determined by the shape of the joint surfaces, the ligament us and capsular tension and the inherent bony structures.

When a concave surface moves on a convex the direction of translation (slide) is in the same direction as that of the motion (rotation).  When a convex surface moves on a concave the translation is in the opposite direction to the motion.

Manual Examination

Objective: to determine the presence presence of vertebral motion (somatic) dysfunction.

Passive Physiological Intervertebral Motion (PPIVM’s)

Passive Accessory Intervertebral Motion (PAIVM’s)

Functional Technique

Flexion / Extension

- segmental range

- total range

Side flexion / Rotation

- segmental range

- total range

- coupled motion

- position dependent

Correlation of active movement , PPIVM’s & PAIVM’s to define diagnosis and prescribe optimal treatment strategies.

Saggittal plane motion: nutation / counternutation

Range:

Intra-pelvic motion a function of:

Inominate position (functional test in Siting)

Sacral position

Spinal position

Manual Examination Techniques

Physiological Motion

Lumbar flexion

Lumbar extension

Lumbar side flexion

Lumbar rotation

Lumbar shear

Accessory Motion

PA’s

Unilateral’s

Transvers’s

In combined positions

Positional assessment:

ASIS

PSIS

Iliac Crest

Standing hip flexion test

Standing hip extension test

Positional assessment:

Sacral base

Inferior lateral angles

Accessory glide

Shear (stress) test

Enjoy the clinical challenge

David

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