Exam 1 Flashcards
Level of Irritability - Red
Pain before resistance
Level of Irritability - Yellow
Pain and resistance happening at the same time - perform isometrics
Level of Irritability - Green
Pain after resistance, good to go
Stage of Healing
Acute: 7-10 days
Sub-acute: 10 days to several weeks
Chronic: several weeks
MS problems are typically influenced by?
Movement or positions
Intermittent pain is usually caused by?
Prolonged postures, loose intra-articular body, impingement of a MS structure
Peripheralization
getting worse
Centralization
getting better
System Review
Determine if the patient is appropriate for PT
Red flags for cancer
Night pain
Unexplained weight loss
Constant pain
Tests and Measures are used to?
confirm or reject a clinical hypothesis
Support clinical judgement
Scanning Examination Purpose
rule out symptom referral
rule out serious pathology
ensure correct diagnosis
assess contractile/lnert tissues
When do you perform scanning examination?
no history of trauma
no history to explain signs & symptoms
redicular sign present
trauma with radicular sign
spinal cord signs
abnormal patterns or movement
suspected psychogenic pain
When can scanning be hold off?
history of trauma
recent surgery
What is included in a scanning?
PROM, AROM, ARM with resistance
Altered sensation
dermatome
Weakness in the nerve root
Myotome
Grading of Deep Tendon Reflex
0 - absent
1- diminished
2 - normal
3 - exaggerated
4 - clonus
Informal Observation
Body Language
Facial Expression
Fear
Attitude
Assistance
Contraindictions - Precautions with AROM
Suspected fracture
Fracture Healing Process
surgical considerations
irritable joint
excessive pain
Limitation in AROM
Strength
flexibility of anatagonist
arthro
neuromuscular control
nerve innervation
pain
limitation in PROM
Flexibility
arthro
pain
contractile
muscle belly
tendon
injury to anything that creates tension
inert
joint capsule
ligaments
bursa
articular surfaces of the joint
bone
contractile lesion
pain with Active contraction, PROM stretching, AROM resisted
Passive movement is painful in opposite direction
Active movement is painful in one direction
Inert Lesion
Active and passive movements painful in the same direction
Pain at end range
Resisted movements are not painful at neutral position
Full ROM & No pain
no lesion of the tested inert tissue
Pain & Limited ROM in every direction
Entire Joint affected / Capsular pattern
Pain & Excessive or limited ROM in a non-capsular pattern
Lesion of inert tissue (ligament)
Painfree, limited ROM
Precursor OA
Contractile Tissue Lesion
AROM or PROM is painful in the opposite direction
Normal Joint play
Hurts with resistance
Inert Tissue lesion
AROM and PROM limited and painful in the same direction
Resistance at neutral can be pain free
Capular Patterns
Pattern of limitation or restriction in ROM
Restricted in most or ALL ROM, whole capsule
Purpose of MMT
Testing muscle weakness / injury
Peripheral nerve injury
Myotome assessment
nerve root injury- radiculopathy
Fatigable weakness
Isokinetic strength testing
General muscle strength
Example: Post ACL Injury
Resisted Isometrics
distinguish between cotractile lesion vs Inert Lesion
At Neutral/ Open Pack position (most relaxed position) - discomfort : contractile injury, because Inert structures are at rest
Resisted Isometric testing
- Strong & Painless: Contractile tissue not involved
- Strong & Painful: Minor lesion of contractile tissue
- Weak & Painless: complete rupture of contractile tissue
- Weak & Painful - Major lesion of contractile tissue
- Painful on Repetition: Intermittent Claudication
Muscle weakness
peripheral nerve damage
within muscle belly itself
Fatigable weakness
Nerve root Issue
Muscle with the same innervation level will experience the same issue
Closed Pack Position
Maximally congruent - Most stability
Twist of Joint capsule & ligaments
Fractures & Dislocations typically occur in?
Closed Pack Position
Compression
movement into CPP
Distraction
Movement out of CPP
Open Pack Position
Capsule & Ligaments on Maximum Slack
Maximal “Joint play”
Capsular or ligamentous sprains typically occur in?
Loose or open packed position
Physiological motion
Result of concentric or eccentric active muscle contractions
Accessory Motion
Occurs inside the joint
Roll
Series of points in contact with a series of points
Spin
rotating around an axis
Slide
Specific point in contact with a series of points
Compression
Decrease in space between two joint surfaces
Distraction
Two Joint surfaces pulled apart
Maitland’s Joint Play assessment
0 - mobilization is not indicated
1- 2 Hypomobility
3 Normal
4-5 Hypermobile
6 Unstable
Normal End Feels
Bone to bone - at full ROM
Soft tissue - Compression of soft tissues
Tissue Stretch - Elastic or springy resistance at end range of movement
No stretching when
Pain before ROM where resistance is met
Management Plan
Goals
Progonosis
Intervention
Summary of plans
Joint Play Assessment: Glides
Unrestricted & Normal - Soft tissue mobs
Unrestricted & Excessive - stabilization exercises
Restricted: Joint mobilization
Joint Play Assessment: Distraction
Limited: connective tissue contracture
Increase Pain: Connective tissue tear
Decrease Pain: Implicates Joint surface
Neurophysiological effects
Stimulates Mechanoreceptors to decrease pain
Nociceptive stimulation
Nutritional Effects
Exchange of fluids to improve joint mobilization
Mechanical effects
Breakup adhesions to increase glide
Absolute contraindications to passive movements
Malignancy of target area
Rheumatoid collagen necrosis
Unstable upper cervical spine
Vertebral basilar insufficiency
Relative contraindications to passive movements
Active, acute inflammatory conditions
Acute nerve root irritation
Blood clotting disorder
Condition is worsening with treatment
Rules of Mobilization
Both therapist and patient are relaxed
Don’t move through pain
one hand stabilizes one hand mobilize
One movement at one joint
Re-assess after each maneuver
Maitland Joint Mobilization grading Scale
Grade I - Small amplitude oscillating movement at beginning of range of movement (Decrease pain)
Grade II - Large Amplitude within midrange of movement (Decrease Pain)
Grade III - Large Amplitude up to point of limitation (Improve ROM)
Grade IV - Small amplitude at very end range of movement (gain motion within the joint)
grade V - Thrust technique
Indications for Mobilization
Grades I and II - primarily used for pain
Grades III and IV - primarily used to increase motion
Direction of movement during treatment is either
Parallel - compression
Perpendicular - Glides
Kaltenborn Traction Grading
Grade I - loosen
Grade II - take up slack
Grade III - stretch
Kalternborn grade I
Used initially to reduce chance of painful reaction
Kalternborn Grade III
used in conjunction with mobilization glides for hypomobile joints
Inflammation (stage I)
Avoid painful positions
AAROM or general PROM
Grade I joint mobilization
Prevent Arthrofibrosis
Sub isometrics
Migration and Proliferation (Stage 2)
Controlled activities
Isometrics to Isotonic
Prevent scar contracture
Grade II joint mobilization
Progress ROM
Remodeling (Stage 3)
Concentric & eccentric training
SAID principle - customized to the activity
Grade II - IV joint mobilization
Anterior to Greater Troc
Glute min
Lateral to Greater Troc
Glute Med
Posterior to Greater Troc
Bursa
Location of Lumbar Spine Pathology
Buttock and LBP
Hyaline Cartilage
Allows frictionless motion
The higher the peak pressure, the thicker the cartilage
Avascular - no blood pressure
Aneural - no nerves
Alymphatic
Elastic cartilage
Highly specialized
Articular Cartilage Injury
Lesions generally do not heal
Believed to progress to severe forms of OA
Importance of Articular Cartilage Injury
Constant repair but a slow process
Gradual thinning of the articular layer occurs
Outerbridge Classification of Cartilage Damage
Grade 0 -Normal
Grade 1- cartilage softening and swelling, blisters
Grade 2 - Partial- thickness loss, less than 1.5 cm in diameter
Grade 3 - Fissuring to the level of subchondral bone more than 1.5 cm
Grade 4 - exposed subchondral bone
Cartilage healing
Limited ability to repair itself
Closer to blood supply - better healing
No inflammatory stage, no blood supply
Defects less than 3mm wide tend to heal completely
Defects greater than 9 mm wide do not heal completely
Motion enhances the healing of chondral defects (Active motion vs. Passive motion)
Osteochondritis Dissecans
Most common - Medial portion of the medial femoral condyle
Fractures of the proximal and distal segments are either
Extra-articular or articular
Extra-articular fractures
do NOT involved the articular surface
Partial articular fractures
involve only one part of the articular surface, while the rest remains attached to the diaphysis
Complete articular fractures
the articular surface is disrupted and completely separated from the diaphysis
Types of Forces that Commonly Produce Fractures
Tension - Avulsion, transverse fractures
Compression - Impaction fractures
Bending - short oblique fractures
Torsion - Spiral fractures
Comminuted - High energy forces
Cartilage healing doesn’t have which phase?
Inflammatory phase
Bone healing
- Inflammatory phase
- Reparative Phase - Soft callus Formation
- Remodeling Phase - Hard callus Formation, up to 1 year, Wolf’s Law
items that affect the rate of fracture healing
Blood Supply - better blood supply, better healing
Location - closer to the blood supply - better healing
Age
Displacement of fracture fragments
Small space between the fracture structure - Better Healing
Slow Healers
Patients with Diabetes
Smokers
long-term steroid use
Poor Nutritional state
Phases of fracture Management
- Diagnosed - confirmed exp: X-ray
- Reduced if needed: put it back in place
- Stabilize / Immobilize
- Rehab
Delayed Union
Non-union
Mal-union
Delayed union: Taking longer to heal, still healing
Non-union: Healing is finished, fracture still there
Mal union: Healed, but not in good alignment
Pathologic Fracture
Tumor in the femur - femur fractures
Structure affecting the fracture
Osteoporosis
Osteopenia
Osteomalacia
Osteomyelitis
Osteoporosis - softning of the bone
Osteopenia - Precursor of Osteoporosis
Osteomalacia - Softning of the bone, but different than osteoporosis
Osteomyelitis - inflammation around the Bone
Non-Operative treatment of Fractures
Casting - closed reduction
Splints/ Fracture Braces
Surgical Treatment of Fractures
Precutaneous Pinning - small fracture, pins outside
External Fixation - pins on the outside, increase pressure
Intramedullay Nailing - femoral fracture
Immobilization
small bones - 3 weeks
long bones - 8 weeks
While in a cast
submax isometrics
Cast removed
Controlled stresses - gaining strength in the new motion
Salter Harris Classification
type I: separation between metaphysis & epiphysis
type II: separation and fracture on metaphysis
type III: separation and fracture on epiphysis
type IV: on both metaphysis and epiphysis
compression: on growth plate itself
Treatment for Salter Harris Classification
Type I: Non displaced - immobilization
Displaced: closed reduction & immobilization
Type II: Closed reduction & immobilization - cast
Type III: Open Reduction & immobilization
Type IV: need surgery
Type V: stop growth plate
Tendon Injuries (Strain)
Tendonitis: Inflammation, Microscopic Tearing
Tendinosis: Degenerative process, increased risk for Rupture, lack of inflammatory cells
Tendon Rupture
Pain free
Tendon Degeneration - decreased elasticity + Acceleration/deceleration force
Tendinopathy
absent or minimal inflammation
failed healing response
Causes of Tendinopathy
Mechanical Theory - Overload (overuse)
Vascular Theory - Poor Blood Supply
Neural Theory - Neurotransmitters / Mediators
Tendons that are vulnerable to Overuse injuries
-Wrap around a convex surface or the apex of a concavity
-Cross two joints
- low vascular supply
- repeptitive tension
Phases of pain
Phase I: pain less than 24 hours after exercise
Phase II: pain after exercise 48 hours
phase III: Tolerable pain with exercise activity
Phase IV: pain with exercise that alters activity
Phase V: pain caused by heavy activities of daily living
Phase VI: Intermittent pain at rest does not disturb sleep
Phase VII: Pain disturb sleep
Ligaments
Connect bones across joints
Guides/ checkreins to normal motion
Ligamentous injury
Point Tenderness
Joint Effusion
History of Trauma
Ligament Injuries (Sprains)
First degree - hurt to touch, no increased excursion
Second Degree - stretch increase excursion
Third Degree - gone, no end feel
Muscle injuries
Strains
Contusions (Bruise Injury)
Exercise-induced muscle injury
Muscle Strains
All degrees hurt with palpation
-First degree: strong & painful (a few fibers torn)
-Second degree - Bruises
-Third degree - torn, muscle tear
3 Phases of Healing
-Phase I Inflammatory: 48-72 hours to 14 days
-Phase II Reparative & Proliferation: 2-6 weeks
-Phase III Remodeling & Maturation: 6 weeks - 1 year
Subluxation
Partial or incomplete dislocation
Dislocation
bone is forced out of the joint as a result of tearing of the ligaments & joint capsule
Bursae
Fluid-filled sac
Reduce friction between surfaces
Primary: Degenerative changes, RA, Gout, Infection
Secondary: inflammatory, Repeated microtrauma
Classification of Nerve injuries
- Neuropraxia: Transient paralysis, temporary compression
-Axonotmesis: Complete paralysis, recovery can be complete
-Neurotmesis: Complete loss of axon & Schwanna Sheath, Recovery is rarely complete
Clinical Signs of Nerve Compression
-Pain on stretch
- Provocation of pins & needles
- Tenderness & swelling of sheath
- Postural deformity (Lateral trunk shift)
- Decreased conduction (weakness)
- Relief following steroid infiltration
Somatic Referred Pain
Ligaments, Joint Capsule, Annulus
Improvement in pain in a sitting position
ruling out the hip
Lumbar stenosis
Hips Symptoms get worse with
-Activities
- Twisting, turning, or changing directions
- Seated positions with hip flexed
- Rising from the seated position
Trochanteric Bursitis
inability to lie on their side
Intra-articular hip pathology
Clicking, snapping, or pain with movement of the hip
Patients with pain caused by hip pathology
- 7x more likely to have a limp and groin pain
- 14x more likely to have limited IR
Strongest predictors of Cancers in patients with complaints of hip and LBP
- previous history of cancer
- age over 50
- failure to improve with conservative care
- unexplained weight loss
Red Flags for the Hip
- Hip pain in men with testicular cancer
- Pain at MC Burney’s point
- Blumberg’s Sign - rebound tenderness for visceral pathology
