Final Flashcards
What is a plane?
• A flat surface determined by the position of three points in space: sagittal; frontal (coronal); transverse (axial)
What is plane motion?
• Motion in which all points of a rigid body move parallel to a fixed plane (2-D)
What motion occurs in the sagittal, frontal, and transverse planes?
- Sagittal: flexion, extensions
- Frontal: right lateral flexion, left lateral flexion
- Transverse: rotation
What is out of plane motion?
• All points of a rigid body do not move in a single plane (3-D)
What is an axis?
• A line; rotation or translation occur around /along it
What is the x-axis?
• Line passes horizontally from side to side; frontal or coronal axis; mov’t around it is in sagittal plane
What is the y-axis?
• Longitudinal or vertical axis; perpendicular to ground; axis of the transverse plane
What is the z-axis?
• Sagittal axis; lie from back to front; axis of the frontal plane
What are degrees of freedom?
• Number of ways a body can move; one degree is translation or rotation about one axis; spinal segments have 6 degrees (3 translations and 3 rotations)
What is the instantaneous axis of rotation (IAR)?
• An axis perpendicular to the plane of motion that passes through a point that is instantaneously not moving; used to describe any vertebral motion in a 2-D plane; can shift with different force vectors applied to a vertebra; differs under changing loads, and is different for cervical, thoracic, and lumbar spinal segments
What is a motion segment?
• The functional unit of the spine; smallest spinal segment with biomechanical characteristics similar to those of entire spine; 2 adjacent vertebrae and their interconnecting disc, joints, capsule, and ligaments; 6 degrees of freedom
What is coupled motion?
• Consistent association of one motion (translation or rotation) about one axis with another motion about a second axis; one motion cannot be produced without the other; two motions occurring at the same time along two different axes
What is an example of coupled motion?
• Bending neck to left or right, to the left involves right coupled axial rotation of the upper cervical spine, and left coupled AR of the subaxial cervical spine; and vice versa
What is loose-packed joint position?
• Joint capsule and ligaments are most relaxed; maximum joint play is possible; articulating surfaces are maximally separated; position used for traction or joint mobilization; Ex: when facet joints are half-way between flexion and extension
What is closed-packed joint position?
Capsule and ligaments are maximally tightened; there is no joint play; there is maximal contact b/w the articular surfaces; Ex: when facet joints are in full flexion or extension
• What is the breakdown of the vertebrae, including numbers in regions and curvature?
o 33 vertebrae- 7 cervical, 12 thoracic, 5 lumbar, sacrum (5 fused), coccyx (4 fused)
o Kyphosis in thoracic and sacral; lordosis in cervical and lumbar
• What are the regional spinal coupling patterns seen in left lateral flexion?
LLF outweighs RLF, which is seen to some degree in C2-T1(slight) and T1-L1 (moderate)
• What is the flexion-extension regional range of motion of vertebrae?
o Cervical: great, peaks at C4
o Thoracic: low
o Lumbar: greater, peaking at S1
• What is the lateral bending regional range of motion of vertebrae?
o Cervical: high, peaks at C3-C4
o Thoracic: lower/moderate, no peaks
o Lumbar: moderate, peaks at T12, L4
• What is the axial rotation regional range of motion of vertebrae?
o Cervical: great peak at C1
o Thoracic: higher than most C, and L, peak at T1
o Lumbar: very little
• What is the breakdown of flexion and extension regional range of motion of vertebrae?
o Flexion: lumbar most, then cervical, then thoracic (all roughly similar)
o Extension: cervical most, then lumbar, then thoracic (T and L ~same)
-~ 135d total both flex and ext
• What is the breakdown of lateral flexion regional range of motion of vertebrae?
o Equal to right and left; cervical -> lumbar -> thoracic (roughly equal); <90d total to one side
• What is the breakdown of regional axial rotation range of motion of vertebrae?
o Equal to right and left; cervical -> thoracic -> lumbar; ~170 total to one side
• What is the articular anatomy of the occiput (CO)?
o Has 2 condyles, face laterally and inferiorly, form convex rockers, sit in concave surface of superior articular facet of C1
• What is the articular anatomy of the Atlas (C1)?
o Has 2 superior articular facts, concave surface, face medially and superiorly, complement condyles, allow occipital condyles to rock
• Describe the articulation of CO-C1 flexion and extension:
o Occiput glides posteriorly (flexion) and rolls anteriorly (extension); greatest ROM in CO-C1; excursion is 10 d flexion and 25 d extension
• Describe the articulation of CO-C1 lateral flexion:
o Occiput rolls on side of lateral flexion and glides on opposite side; ROM 5 d each side (minimal)
• Describe the articulation of CO-C1 rotation:
o Occiput glides posteriorly on side of rotation and anteriorly on side opposite rotation; limited by alar lig (taut on side opp rot); ROM 5d each side (minimal)
• What is the articular anatomy of the C1-C2 (atlas-axis) jt?
o Two facet jts plus the atlas-odontoid jt; planes of facet jts of C1-C2 are mostly horizontal; inferior facets of C1 are slightly convex and face inferior and medially, superior facets of C2 are slightly convex (yes, both are convex) and superior and laterally
• Describe the atlas-odontoid jt:
o Synovial jt b/w odontoid and anterior arch of atlas; transverse lig courses around posterior aspect of odontoid
• What are the occipital-odontoid and atlas-odontoid ligs?
o Alar lig b/w occiput and odontoid
o transverse lig courses around posterior aspect of odontoid
• Describe the articulation of C1-C2 flexion and extension:
o Flexion: C1 articular surfaces glide posteriorly (minimal)
o Extension: C1 articular surfaces glide anteriorly (minimal)
• Describe the articulation of C1-C2 lateral flexion:
o Limited active ROM (5d each side, minimal)
o Articular surfaces of C1 slide (translate) on articular surfaces of C2 toward the side of lateral flexion
• Describe the articulation of C1-C2 rotation:
o Very mobile, accounts for ~ half of cervical rotation; C1 rotates around odontoid in horizontal plane; C1 articular surface glides posterior on the side of rotation and anterior on the side opposite of rotation; ROM avg 40d each side; first 25d occur exclusively at C1-C2
• Describe the articulation of C2 flexion and extension:
o Primarily translation
o Flexion: anterior disc compression (posterior distraction); facets glide apart producing stretching and joint gapping
o Extension: anterior disc distraction (posterior compression); facets approximate (compression at inferior margins)
• Describe the articular anatomy of the lower cervical biomechanics (C3-C7):
o Design is consistent from C3-C7; vertebral body wider transversely than A-P; transverse foramen for vertebral artery
• Describe the articulation of the lower cervical biomechanics (C3-C7):
o Articular facets are at 45d with transverse (horizontal) plane, parallel in frontal (coronal) plane (meaning don’t face medially/laterally); articular surface is nearly flat
• What is the joint of Luschka?
o In C3-C7; aka uncinated process; the interbody jts (uncovertebral jts); from age 6-9, completed age 18; limit lateral flexion to only a few degrees; serve as guides to couple lateral flexion with rotation (coupled motion)
• What is the cervical curve?
o Lordotic curve of 20-50d (avg is 45); C1-C7; facet and disc planes determine curve; secondary curve; develops in response to upright posture
• Describe the cervical disc of C3-C7:
o Disc height to body height ratio is 2:5 (allows for greater ROM in cervicals); 25% of height of cervical curve; higher anteriorly (contributes to cervical lordosis); nucleus pulposus slightly posterior to center
• Describe the articular anatomy and ROM of lower cervical flexion and extension (C3-C7):
o Flexion and extension predominate over other motions; average ROM is 15d per segment for combined flexion-extension; mid cervicals have the greatest range in flexion-extension at 20d (lowest is C2-C3 and C7-T1 at 10d); movt is combo of segmental tipping (sagittal rotation) and gliding (sagittal translation)
• Describe the articulation of lower cervical flexion and extension (C3-C7):
o Flexion: anterior disc compression (posterior distraction); facets glide apart producing stretching and jt gapping
o Extension: anterior disc distraction (posterior compression); facets approximate (compression at inferior margins)
• Describe the articular anatomy and ROM of lateral flexion (C3-C7):
o Average lateral flexion range is 7-8d to each side; lateral flexion decreases as move caudally down cervical spine; coupled motion (lateral flexion is coupled with ipsilateral axial rotation); the degree of coupled rotation decreases in a cephalic to caudal direction
• Describe the articulation of lower cervical lateral flexion (C3-C7):
o Lateral disc wedging and approximation are present on the side of lateral flexion and distraction is present on the side of opposite lateral flexion
o The inferior facet glides down and medially on the side of lateral flexion and up and laterally on the side opposite lateral flexion
• Describe the articular anatomy and ROM of lower cervical rotation (C3-C7):
o Avg rotation ROM is 5d to each side; rotation decreases significantly at C7-T1 (avg is 2d); predominantly axial rotation coupled with ipsilateral flexion; the vertebral bodies lateral flex to the side of rotation; the coupling is not as strong as that noted with cervical lateral flexion
• Describe the articulation of lower cervical rotation (C3-C7):
o On the side of rotation the inferior facet glides down and medially; on the side opposite rotation the inferior facet glides up and laterally (coupled rot and LF)
• What ligaments or muscles, etc limit each of the cervical motions?
o Flexion: Ligamentum nuchae; Ligamentum flavum; posterior atlanto-occipital membrane and jt capsule
o Extension: anterior longitudinal ligament; anterior capsule of facet jt; atlanto-occipital membrane and jt capsule
o Lateral flexion: rectus capitis lateralis; capsule of facet jt
o Rotation: capsule of facet jt; alar ligament
• Describe the articular anatomy of the typical thoracic biomechanics (T2-T8)
o Transverse processes are thick, strong and long; spinous processes are long and slender; costovertebral jts on side of vertebral body articulate with rib heads; costotransverse jts on transverse process articulate with tubercles of ribs; sup (lat and post) and inf (med and ant) articular facets; sup and inf costal facets; articular facets form 60d from transverse toward coronal plane, and 20d from coronal to sagittal
• What are the atypical thoracic vertebrae?
o T1: resembles C7, has whole facet for articulation with 1st rib
o T9-T12: variations on location of facets on body and TPs for articulation w/ ribs
o T11 and T12: begin to take on characteristics of lumbar vertebrae
• What is the thoracic curve?
o Kyphotic of 20-50d (avg is 45d); from T1-2 to T12; apex at T6-7; primary curve at birth
• What will flattening of thoracic curve cause?
o Cervical curve to decrease and shift forward; lumbar curve to increase
• Describe the thoracic disc:
o Disc height-to-body height ratio is 1:5 (smallest in spine); contributes to decreased flexibility in thoracic spine; nucleus pulposus located centrally within annulus
• Describe the articular motion of thoracic flexion and extension:
o Avg is 6d (4d upper, 6 middle, 12 lower); combines sagittal plane rotation with slight sagittal plane translation (minimal); flexion (facets glide apart as disc opens posteriorly); extension (facets and posterior disc approximate)
• Describe the coupled motion of thoracic lateral flexion:
o Avg 6d to each side; upper is coupled with axial rotation, occur to same side (body rotation to the concavity and spinous deviation to the convexity); middle and lower, coupling may occur in either direction; disc and facet approximate on side of lf and separate on opposite; upper thoracic inf facets glide medially on side of lf and laterally on opposite due to strong coupled axial rotation
• Describe the motion of thoracic rotation:
Upper avg 8-9d to each side, decreases in middle and minimal in lower; upper is coupled with same-side LF; inf facets glide inferiorly on same side of rotation and superiorly on opp
Name all the ligaments of the thoracic spine. Facets?
o Anterior longitudinal lig; interarticular lig of head of rib; lateral costotransverse lig; intertransverse lig; superior costotransverse lig; radiate lig of head of rib
o Inf costal facet (head rib); superior costal facet (head); transverse costal facet (tubercle of rib)
• What is the “pump handle action” motion of the ribs?
o with inspiration, ribs T1-6 are pulled up and forward; pump handle movt increases the AP diameter of rib cage; rib head rolls down, elevating anterior end of rib like handle of pump
• What is the “bucket handle action” motion of the ribs?
o With inspiration, ribs T7-T10 are elevated and depressed; bucket handle movt increases transverse diameter of rib cage; ribs ride up and down on TP while rib elevation and depression is like a bucket handle on hinges
• What is the “caliper action” motion of ribs?
o With inspiration, ribs T8-12 move laterally; caliper movt increases lateral diameter of rib cage
• Describe thoracolumbar flexion, and what limits it:
o Agv is 85d (bend over, reach toes); overall limited by hamstrings; thoracic does most of bending, limited by interspinous and supraspinous ligs; lumbar goes from lordotic to straight, limit by ligs, capsule of facet jt; and compressed annulus fibrosus
• Describe thoracolumbar extension, and what limits it:
o Avg is 35-40d (up dog) limited by hip flexors; thoracic limited by anterior longitudinal lig; thoracic goes from kyphotic to straight; lumbar has more mobility, limited by lig, and capsule of facet
• Describe thoracolumbar lateral flexion, and what limits it:
o Avg is 45d to each side; thoracic by superior facet of T6 and T7; lumbar by superior facet of L1 and L2, inferior facet of L1, intertransverse lig
• Describe thoracolumbar axial rotation, and what limits it:
o 35d (although cervical is 90, so total head rotation is 125); thoracic limit by sup-inf facets of T6-7; lumbar limit by sup-inf facet of L1-2, jt approximation on one side, separation on other
• Describe the articular anatomy of the lumbar vertebrae (L1-L5):
o Pedicles and laminae are short, broad and strong; mammillary processes on ant/sup part of SPs; SPs are thick and broad; TPs are long, slender and flattened on their anterior and posterior surfaces; facets primarily in sagittal plane but become more coronal at lumbosacral junction; greatest mobility is in Flex/ext; facet orientation limits rotational flexibility
• What are the angles of the lumbar facet joint orientation?
o Articular facets are parallel to longitudinal axis, 45d anteriorly
• Describe the lumbar curve:
o Lordotic of 20-60d (avg 35); from L1-2 and extends to sacrum; apex at L3-4; secondary curve (from birth), in response to standing; anterior pelvic tilt increases lordosis; posterior pelvic tilt decreases it
• Describe the lumbar discs:
o Disc height-to-body height ration 1:3 (allows ROM); nucleus pulposus located posteriorly within annulus; allows for movt; resists axial compression forces
• What is the compression force transition through a lumbar disc?
o Compression force from body weight and muscle contraction raises hydrostatic pressure in nucleus pulposus; increases pressure elevates tension in annular fibrosis; increased tension in annulus inhibits radial expansion of nucleus; increased nuclear pressure is exerted up and down against endplates; pressure w/I nucleus reinforces peripheral annulus fibrosus creating a stable weight-bearing structure
• How is weight normally distributed onto discs?
o Oval 2-D surface is split into 4 90d quadrants, each bearing 25% the weight
• What is a disc bulge?
o Shallow generalized extension of the disc tissues beyond the edges of the vertebral body (<3mm); annular fibers buckle out; may compress neural tissue in IVF or spinal canal; pain; jt dysfunction; NOT a herniation; bulging is a descriptive term for the shape of the disc and is not diagnostic;
• What are symmetrical and asymmetrical bulging discs?
o “symmetrical”= bulge is symmetrical “circumferentially” beyond edges of vertebral body (proportionately enlarged diameter, etc)
o “asymmetrical”= asymmetrical bulge of disc margin (as is found in severe scoliosis)
o Neither are considered a form of herniation
• What is a disc herniation?
o Disc material ruptures through the annular fibers, beyond limits of IV disc space; may compress nerve in IVF; may cause radicular pain (radiating, dermatome); intense inflammation; torn annular fibers cause somatic pain
• What are “focal” and “broad-based” disc herniations?
o herniations are “localized” process involving <25% (90d)
o “broad-based”= 25-50% (90-180d)
• What do protrusion and extrusion mean in regards to disc herniations?
o Protrusion: base of herniation is broader than the distance it protrudes into spinal canal
o Extrusion: disc balloons into canal with a comparatively narrow base, as if trying to bud off; may become sequestered
• What are annular tears?
o Radial, transverse or concentric tears (fissures) in annulus; may weaken disc; may generate pain; disc may migrate into tears
• Describe lumbar flexion and extension:
o Avg 15d; combines sagittal plane rot with slight sag plane translation (minimal);
o Flexion: vertebra tilts and slides anteriorly; facets glide superiorly; disc is compressed anteriorly and stretched posteriorly
o Extension: vertebra tilts posteriorly; facets approximate; facet capsule, disc and anterior long lig are stretched anteriorly
• Describe lumbar lateral flexion:
o 6d to each side; lumbosacral only 3d; coupled with opposite side rot; facets on side of LF glide together; facets on opp side glide apart
• Describe the coupled motion of lumbar lateral flexion:
o Coupled with opp side rotation: body rotation to convexity and spinous deviation to concavity; this is opp of coupled motion in cervical and upper thoracic spine
• Describe the motion of lumbar rotation:
AR is very limited by sagittal facets (avg 2d); facets glide apart on side of rot, and approx. on opp side; rot is coupled with LF and slight sagittal plane rot; rot of L1-L3 is coupled with opp side LF; rot of L4-L5 is coupled w/ same side LF
• Describe the functional anatomy of the pelvis:
- Two innominate (coxal=fused ilium, ischium, pubis) bones
- pubic symphysis (amphiarthrosis, slightly movable jt, Fibrocartilaginous disc)
- sacrum: facets of superior articular processes; articular surface (w/ilium); median sacral crest (2nd sacral tubercle)
• What is the three joint complex of the pelvis?
- 2 SI jts and a Pubic symphysis
- SI articular surface of innominate: diarthrosis, fibrocartilage, central convex ridge; heavy lig attachments on posterior and superior surfaces
- SI articular surface of sacrum: diarthrosis; “L” shaped (boot shaped)’ hyaline articular cartilage; central groove (concavity)
• What is the “Z” joint?
• L5-S1 zygapophyseal jt
• What are the ligs of the posterior pelvis
• Iliolumbar; posterior SI; interosseous SI; dorsal SI; deep dorsal sacrococcygeal; sacrospinous; superficial dorsal sacrococcygeal; Sacrotuberous
• What are the ligs of the anterior pelvis?
• Anterior SI; iliolumbar; SI jt; pubic symphysis
• What is the keystone effect in pelvic statics?
• Sacrum forms the keystone of an arch suspended by strong SI ligs; inf displacement is resisted by wedge shape of sacrum; post displacement is resisted by the SI ligs; ant displ resisted by SI ligs and pubic symphysis
• What is the self-locking mechanism in pelvic statics?
- FORM closure (anatomy of SI jts promotes stability); wedge shape of sacrum; interlocking groove (sacrum) and ridge (ilium); “S” shaped jt surfaces
- FORCE closure (tension in mm, ligs, and fascia aids in stabilizing the SI jts)=posterior myofascial sling (lat dorsi, thoracolumbar fascia, glut max); creates lat-med pressure from ilium to sacrum, compressing SI jts; creates ant closure of pubic symphysis
• What is the shock absorber aspect of pelvic dynamics?
• Transmit force b/w lower extremity and axial skeleton; slides and pivots to absorb and adapt to forces generated b/w trunk and LE during locomotion; decreases stress to lumbar spine and opp SI jt
• What is nutation and counternutation of SI motion?
- Nutation: Sacral base rotates anteriorly on ilium, or ilium rotates posteriorly on sacrum, or both
- Counternutation: sacral base rotates posteriorly on ilium, or ilium rot ant on sacrum, or both
• What does moving into nutation or counternutation create:
- Nutation: ant sacral tilt; post iliac rot; increased lumbar Lordotic curve
- Counternutation: post sacral tilt; ant iliac rot; decreases lumbar Lordotic curve
• What are the dynamics of pubic symphysis movt?
• Compression; distraction (separation); rotation in sagittal plane with SI jt motion; gliding (translation, A-P, sup-inf)
• What is the reciprocal motion b/w the ilium and sacrum during locomotion?
- Flexion of the hip and ilium (post inf movt of the PSIS) is accompanied by ipsilateral ant inf movt of sacral base (SI flexion)
- Extension of hip and ilium (ant sup movt of PSIS) is accompanied by ipsilateral post sup movt of sacral base (SI extension)
• What is the force couple for anterior and posterior pelvic tilt?
- Anterior: hip flexors (Iliopsoas and rectus femoris) and back extensors (erector spinae)
- Posterior: hip extensors (gluteus maximus and hamstrings) and abdominal muscle (rectus abdominus and obliquus externus abdominus)
• What are the ranges of lumbopelvic flexion (normal and limited)
- Normal, can reach toes
- Limited hip flexion with excessive lumbar flexion
- Limited lumbar flexion with excessive hip flexion
• What did Hippocrates (460-377 BC) write about manipulation? Quote?
- “Manipulation and importance of Good Health” and “Setting Joints By Leverage”
- “Get knowledge of the spine, for this is the requisite for many diseases
• What did Claudius Galen do?
• 130-200 AD; “Look to the nervous system as the key to maximum health”; famous for treating scholar Eudemus, manipulated his neck, which apparently cured a paralysis of hand and arm
• What is the biomechanical model for jt manipulation and mobilization?
• Biomechanical principles can be used to explain jt dysfunction; biomechanical info can be linked w/ neurophysiology to explain the role of jt dysfunction in pain and altered physiological function
• What are the 2 biomechanical approaches to jt assessment?
- Static model: structural emphasis, “bone out of place”
* dynamic model: functional emphasis, “loss of motion”
• What is the basis for the static model?
- Alterations in POSITION of adjacent bones create changes in mechanical and neurological function of a jt
- Based on idea of “structure determines function”; static position determines how well a jt functions
• How is malposition determined in static assessment?
• Static palpation; markings on x-rays; special instruments (thermography, electromyography, etc)
• What are advantages and limitations to static assessment?
- Advantages: in acute conds when moving the body is too painful; in areas with limited motion
- Limitations: incorrect assessment due to bony anomalies; may have good static alignment but have faulty jt function (movt); jts may be compensating for biomechanical faults elsewhere and falsely identified as problem (eg lumbar compensation for short leg)
• What is the basis for the dynamic model?
- Alterations in MOTION of adjacent bones create altered mechanical and neurological function of a jt. Mm and ligs contribute to cause of altered motion (mechanical derangement)
- Based on idea that function is often more sig than structure; a mobile jt )free of restrictions) is a healthy jt
• How is restriction determined in the dynamic model?
• Motion palpation (looking for quality and quantity of motion); posture and gait analysis; motion x-rays
• What are the advantages and limitations to dynamic assessment?
- Advantages: identifies components that become dysfunctional (ie jt, soft tissues)
- Limitations: lack of consistent interexaminer reliability; less helpful in acute painful conditions and areas with limited motion; may overlook postural stresses (poor posture, but normal jt movt); motion may be limited by coexisting disease (normal motion is altered)
• What is the naturopathic manipulative therapeutics approach (NMT)?
• Integrates structural (static) and functional (dynamic) analysis; “malposition of a bone” refers to a static finding; “restriction of jt motion” is a dynamic finding
• What is joint dysfunction in abnormal jt mechanics?
• Jt mechanics showing disturbances of function w/o structural or positional change; a subtle mechanical jt alteration affecting quality and range of motion
• What is joint fixation of abnormal jt mechanics?
- An articulation that has become temporarily immobilized in a position that it would normally occupy during any phase of movt
- An articulation that is immobilized in a position of movt when the jt is at rest, or in a position of rest when the jt is in movt
• What is jt restriction in abnormal jt mechanics?
• Limitation of movt; describes the direction of limited movt in a dysfunctional jt; Ex: a vertebra that doesn’t rotate to the right has a “right rotation restriction”
• What are three causes of jt dysfunction?
- Mechanical: macrotrauma (a single traumatic event); microtrauma (repetitive minor cumulative trauma); postural (habitual sedentary posture or continuous faulty posture)
- Chemical: exposure to toxins (environment, food, water); hormonal, inflammatory, auto-immune, chemical stressors; reflex interaction (somato-visceral, viscera-somatic, viscera-visceral reflexes)
- psychological stress: mental, emotional, psychological, spiritual stress; psycho-somato-visceral reflexes
• What is PARTS in identifying jt dysfunction?
- Pain or tenderness produced by static or motion palpation and pressure over structures and soft tissues (note location, quality, intensity)
- Asymmetry of jt components identified by static palpation; bony landmarks, muscle tone
- ROM; decrease or loss of specific movts identified through motion palpation or global ROM; may be active, passive or accessory movts
- Tone, texture, and temp changes in specific soft tissues identified w/ palpation; warmth, puffiness, fibrous, nodular, ropey, hypertonic, induration, contracture
- Special tests or procedures; orthopedic tests and challenges
• What are the 4 steps is assessment of jt dysfunction?
- Inspection/observation
- Palpation: static and motion
- ROM: global (osteokinematics) and articular (arthrokinematics); end-feel
- Naming the jt dysfunction; Listing (static and motion)
• What is the inspection/observation in assessment of jt dysfunction?
- Superficial: size, shape, skin, cuts, bruises, swelling, scars, moles, etc
- Posture; gait
• What are the static and motion aspects of palpation in assessment of jt dysfunction?
- Static: assessment of somatic structures in a neutral state; soft tissues (muscle, tendon, lig, bone, dermal, subdermal)
- Motion: assessment of passive and active segmental jt ROM
- Quantity: how much does jt move?
- Quality: how does jt move thru ROM?
- Jt play: what is the quality of resistance? Too much or too little?
- End-feel: at what pt is it encountered? What is the quality of resistance? When does motion stop?
- Symptoms: does amount or location of pain change during assessment?
• What are 2 ways to measure global ROM in assessment of jt dysfunction?
- Goniometry: limited to extremity jts
* Inclinometry: standard for spinal measurements
• What are the 8 aspects of articular ROM in assessment of jt dysfunction?
- Active ROM: movt accomplished w/o outside assistance; pt moves part himself; physiological movts (osteokinematics)
- Passive ROM: movt is carried through by operator w/o conscious assistance or resistance by pt
- Physiological barrier: the end point of active jt movt
- Jt play: discrete, short range movt of a jt independent of the action of voluntary muscles, determined by springing a bone of an articulation in a “neutral position”
- End-feel (end play): discrete, short range movt of a jt independent of the action of voluntary muscles, determined by springing a bone of an articulation at the “limit of its passive ROM”
- elastic barrier: the elastic resistance felt at end of PROM; further motion toward anatomic barrier may be induced passively by examiner
- paraphysiological space: area of increased movt beyond elastic barrier available after a cavitation w/ the jt’s elastic range
- anatomic limit: limit of anatomical integrity; limit of motion imposed by anatomical structures; forcing movt beyond this barrier would produce tissue damage (jt trauma)
• How is jt motion interpreted in assessment of jt dysfunction?
• Each jt has a characteristic end-feel; a normal end-feel at one jt may be a pathological end-feel at another
• What are the 5 types of end-feel that can be palpated in normal or abnormal conds?
- Capsular: firm but giving; resistance builds w/ lengthening, like stretching a piece of leather; N=external rot of shoulder; A=capsular fibrosis and adhesion
- Ligamentous: like capsular, but may have a slightly firmer quality; N=knee extension; A=resistance due to ligamentous shortening
- Soft tissue approximation: giving, squeezing quality; results from approx. of soft tissue; typically painless; N=elbow flexion; A=muscle hypertrophy, soft tissue swelling
- Bony: hard, non-giving abrupt stop; N=elbow extension; A=bony exostosis, articular hypertrophic changes
- Muscular: firm but giving; builds w// elongation; not as stiff as capsular or ligamentous; N=hip flexion
• What are the 3 types of end-feel that can only be palpated in abnormal conds?
- Muscle spasm: guarded, resisted by muscle contraction; end-feel can’t be assessed b/c of pain/guarding; A= protective muscle splinting due to jt or soft tissue dz or injury
- Interarticular: bouncy springy quality; A= meniscal tear, jt mice
- Empty: normal end-feel resistance is missing; end-feel is not encountered at normal point or jt demonstrates unusual give or deformation; A= jt injury or dz leading to hyper-mobility or instability
• What are “listings” in naming a jt problem?
• Refers to a description of the manner in which the jt is dysfunctional ( naming and recording jt abnormalities); can be either static or motion; for peripheral jts, name the position of the most moveable bone; for vertebrae, name the upper vertebra relative to the lower one of the motion segments (2 adjacent vertebra and the soft tissue that connect them)
• What are static listings?
• Based on findings from static palp and x-ray markings; uses standard jt motion terminology to describe the position of the jt; uses term “malposition” at end of phrase; to label a static malposition, determine the anatomical position of the bone and add the term “malposition”; Ex: flexion malposition; extension mal; right rotation mal; left rot, RLF, LLF, of spine
• What are motion (dynamic) listings?
• Based on findings from motion palpation or dynamic x-ray markings; uses standard jt motion terminology to describe the direction the jt will not move or has lack of springy end-feel; uses term “restriction” at end of phrase; to label a motion restriction, determine the direction the jt will not move and add term “restricted”; Ex: flexion restriction (not moving into flexion), extension, RR, LL, RLF, LLF
• Describe the motion palp assessment of T7:
• Push on left side of SP of T7 to assess motion of the body of T7 into left rotation
• What is the difference b/w mobilization and manipulation?
- Mobilization: passive jt movt for increasing ROM or decreasing pain; accessory or physiologic motions applied to jts and related soft tissues at varying speeds and amplitudes (depths); applies a force that is light enough that a pt can stop the movt; applied from the resting position up to the elastic barrier of the jt
- Manipulation: passive jt movt for increasing jt mobility and reducing pain; uses a high-velocity, low-amplitude thrust that is beyond pt’s control; thrust applied to the end of elastic barrier into the paraphysiological space
• What is the role of facet joints in spinal mobilization and manipulation? Their orientation?
- Control passive jt movt; resist torsion and shear of jts, capsule and soft tissues; load on the jts varies with flexion and extension
- Cervical (45d transverse, parallel frontal); thoracic (60 t, 20 f); lumbar (90 t, 90 f)
• What are the 3 effects of mobilization?
- Neurophysiological: stimulates mechanoreceptors that inhibit transmission of nociception; decreases muscle spasm and guarding due to nociception; stimulates GTOs that inhibit muscle tone; increases awareness of position and motion by stimulating afferent nerves; stimulates proprioceptors
- Nutritional: small movts stimulates synovial fluid that nourishes articular cartilage; movt exchanges nutrients during jt swelling and immobilization; increases nutrition to the avascular portions of articular cartilage
- Mechanical: improve mobility of hypomobile jts (loosens adhesions and scarring); maintains extensibility and tensile strength of articular tissues
• What are the indications and goals for mobilization?
- Indications: improve jt hypomobility or stiffness; decrease pain; decrease muscle spasm or guarding; decrease soft tissue restrictions preventing normal jt motion; reflexogenic effects (facilitate muscle tone or stretch reflex); proprioceptive effects
- Goals: gentle jt play techniques stimulate neurophysiological, nutritional and mechanical effects
• What are the motions used for mobilization?
• Roll, spin, slide (glide), distraction and traction, compression
• What is the rationale for mobilization?
• In order to restore motion in a hypomobile jt, tissue deformation must occur; tissue stretch w/I the elastic range doesn’t produce a permanent structural change; stretching in the plastic range does cause permanent structural changes; jt mobilization can be used to stretch tissue and break tissue adhesions; jt mobilization involves slow, small amp oscillations or traction
• What is the convex-concave rule in mobilization?
- All jt mobilizations follow the convex-concave rule
- If convex surface is moving on stationary concave, gliding occurs in opposite direction of roll (=mobilization is in same direction as joint restriction)
- Concave on convex: glide in same direction as roll (=mobilization is in opposite direction of joint restriction)
• What are some general rules for mobilization techniques?
• Pt and operator relaxed; one hand usually stabilizes, while other performs the movt; operator must consider direction of movt/restricted movt, velocity of movt (slow for large capsular restriction, faster oscillation for minor degree restriction), amplitude of movt (graded according to pain, guarding and degree of restriction)
• What is the general procedure for mobilization techniques?
• Pt is relaxed, distracted, supported so jt capsule is lax; position jt in open position (loose packed); stabilize the proximal bone; apply tx force as close to opposing jt surface as possible; larger contact surface, more comfortable procedure (use flat surface of hand instead of thumb); compare accessory jt movt to opposite side; one movt is performed at a time, at one jt at a time
• What are the Maitland grades of oscillations in mobilization technique?
- I: small amp movt at beginning of ROM; used to manage pain and spasm
- II: large-amp movt b/w beginning and mid-ROM; used to manage pain and spasm
- III: large-amp movt reaching limit of available range; used to increase ROM and decrease stiffness
- IV: small-amp movt at end of available range; used to increase ROM and decrease stiffness
- V: small amp, high-velocity thrust beyond end ROM; used to increase ROM, decrease pain and stiffness
• What are the physiological effects of Maitland graded oscillations?
- I, II, III: neurophysiological effect (muscle tone, axoplasmic flow); stimulate mechanoreceptors; vascular effect; mechanical effect (collagen, jt lubrication, neuromeningeal tissue)
- IV: like I,II,III with greater mechanical mobilizing effect, enhance jt lubrication
- V: like previous, with greater mechanical mobilizing effect, neurophysiological effect, cavitation, enhance jt lubrication
• Describe the Maitland treatment?
• 2-3 oscillations per sec; 3-6 sets of oscillations; tightness (hypomobile, 20-60 sec, grades III-IV, 3-4 times per wk); pain (1-2 mins, grades I-II, treated daily); pain should be treated prior to tightness; small amp oscillations are utilized to stimulate mechanoreceptors, limiting pain perception; typically treat first with modalities (hot pack, ultrasound, laser)
• What are three mobilization techniques of the glenohumeral jt?
• Caudal glide; lateral glide; posterior glide w/ internal rotation
• What are the Kaltenborn grades of traction for mobilization technique?
- I: loosen (low amp); neutralizes pressure in jt w/o actual surface separation; produces pain relief by reducing compressive forces
- II: tighten or take up slack (up to tissue resistance); separates articulating surfaces, taking up slack or eliminating play w/I jt capsule; used initially to determine jt sensitivity
- III: stretch(past tissue resistance, approaching anatomic limit); involves stretching of soft tissue surrounding jt; increase mobility in hypermobile jt
• What is the treatment plane used in Kaltenborn? The general technique?
- Tx plane: traction is applied perpendicular to jt surface (traction); gliding is applied parallel
- Technique: 2-3 oscillations per sec; 3-6 sets; pain 1-2 mins; tightness 20-60 secs
• Describe the Kaltenborn treatment for mobilization?
• Initially use grade I traction to reduce a chance of painful reaction; use 10 sec intermittent grade I and II traction; the distract with grade II and release, allow for return to resting position; use grade III traction in conjunction w/ mobilization for hypomobile jts; grade III and IV oscillations w/I pain limitation to decrease hypomobility
• Name 1 Kaltenborn technique for LE and 3 for glenohumeral jt:
- Tibiofemoral distraction
* Posterior glide w/ traction; longitudinal distraction; distraction w/ oscillations
• What are the contraindications to mobilization and manipulation?
• Malignancy; fracture or dislocation; active bone dz; acute inflammation; acute infection; acute arthritis; vertebral artery dz; ligamentous instability; cauda equine lesions; spinal cord lesions; multiple nerve root involvement; sig anticoagulant or steroid usage; congenital abnormalities
• What is the purpose of gait?
• Bear weight; provide locomotion (pt a to b efficiently); maintain equilibrium
• What are the principles of analyzing gait?
• A pattern of observation should be established so that every detail is analyzed; gait should be analyzed from feet upwards towards head, carefully evaluating every jt from bottom up; pt should walk at normal speed for age; follow-up deviations with other evaluative procedures (mm test, ROM test, movt pattern test, stabilizing and proprioceptive test)
• What are the principles of analyzing gait regarding effect of speed on gait pattern?
- Walking slowly: feet spread out forming a wide base of support; arms and legs to swing less; steps shorter; upper and lower trunk sop rotating; body shifts laterally side to side with step
- Fast: feet come closer together and eventually cross over mid-line; arms with greater excursion; stride length is longer; upper and lower trunk rotate more freely w/ greater amplitude; body translates forward w/ synchronicity
• What is a gait cycle? Phases?
- Initial contact of one leg to initial contact of the same leg
- stance phase (60%, foot on the ground): heel-strike (contact period), foot-flat, mid-stance, push-off (heel-off, toe-off)
- swing phase (40%, when leg is swinging forward): acceleration, mid-swing, deceleration
• When do double and single-limb support occur in the gait cycle?
• Dbl (10%) followed by single on right (40%), then dbl (10%), and single on left (40%)
• Describe the heal-strike of the stance phase, with right foot forward:
- Beginning of stance phase; moment the heal contacts the ground; head and trunk are vertical; arms swing at an equal distance from body; leg is in vertical alignment w/ pelvis; plantar surface of forefoot is visible
- R arm is posterior to midline of body, elbow extended; L arm is anterior w/ elbow partially flexed; pelvis has slight anterior rotations; R knee extended; R foot approx. at right angle to leg
- Just prior to heel strike, hamstrings contract to decelerate leg (which has just completed swing)
- Just after h-s; quadriceps contract to prevent buckling of knee
• Describe the foot-flat of the stance phase:
• Occurs immediately after heel-strike; sole (entire flat) of foot contacts floor; controlled relaxation of foot and dorsiflexors
• Describe the mid-stance of the stance phase?
• Pt at which body passes directly over reference leg; full weight-bearing on reference leg; head and trunk are vertical; arms are near midline of body, at equal distance from body; elbows partially flexed; pelvis has very slight anterior rotation, tilted downward very slightly on left; R knee is in slight flexion; leg is in slight external rotation at hip; swing leg will be passing forward
• Describe the push-off of stance phase. Side view? Front view?
- From heel-off to toe-off, propels momentum forward
- Heel-off: pt following mid-stance at when heel of reference leg leaves ground; gastroc/soleus contract to plantar flex
- Toe-off: pt after push-off when only the toe of reference leg is in contact w/ ground; leads to swing phase
- Side: R arm anterior to midline of body w/ elbow partially flexed; L arm posterior w/ elbow extended; pelvis in anterior rot; knee slightly flexed; ankle plantar flexed
- Front: arms at equal distance from body; leg is slightly externally rotated at hip; plantar surface of heel and mid-foot are visible and forefoot is in contact w/ floor
• What are the 3 parts of the swing phase of the gait cycle?
- Acceleration (initial swing): portion of beginning of swing from moment toe of reference leg leaves ground to pt when reference leg is directly under body; Iliopsoas contract to propel leg forward by flexing hip; knee flexion (raise leg so foot clears ground), and foot and ankle dorsiflexors
- Mid-swing (toe-clearance): portion of swing phase when reference leg passes directly below body; extends from end of acceleration to beginning of deceleration; opp leg is currently at mid-stance
- Deceleration: portion of swing when reference leg is decelerating in preparation for heel-strike; hamstrings and glut max contract (at heel strike, gait cycle begins again)
• What are 6 other components of the gait cycle?
- Pelvic tilt: pelvis drops on side of swing leg, ~5 d, at mid stance of opp leg
- Pelvic rotation: pelvis of swing leg rotates anterior 4d, and thorax rotates posterior 4d; 8d difference
- Pelvic lateral shift: side to side movt during walking; usually 1-2 inches toward stance leg
- Width of base of support: distance b/w 2 feet (at time of dbl stance); usually 2-4 inches
- Step length: distance from one foot strike to the next (ex: left to right)~35-41 cm; = for both legs in normal gait
- Stride length: =one gait cycle; distance of 2 successive steps(1 L and 1R)~70-82 cm= pt of heel strike of one foot, to pt of h s of same foot; = for both legs in normal gait
• What are abnormal gait patterns of stance, mid-stance, and swing phase?
o Stance phase: ataxic gait, abnormal heel-strike; quadriceps weakness; foot flat; foot slap
o Mid-stance: back-knee (hyperextension)
o Swing phase: abnormal pelvic rotation; wide based gait
• What are the 4 types of pain, in differentiating musculoskeletal from visceral?
o Referred: pain perceived at a site adjacent to or distant from the site of origin; ex: pain brought on from myocardial ischemia (angina pectoris, arm pain, neck pain)
o Radiating: pain that moves from the original are outwards to another part of the body; ex: arm and shoulder pain from facet irritation at C5
o Radicular (radiculitis): pain along Dermatomal distribution of a nerve root due to inflammation or other irritation of nerve root; ex: sciatica from irritation of L5 nerve root
o Radiculopathy: spinal nerve root irritation along distribution of a nerve that leads to pain, numbness or muscle weakness and may be associated w/ trophic changes or muscle atrophy. Usually detected by abnormal deep tendon reflexes, muscle strength or sensory tests
• How is location of pain assessed?
o Is it over a specific anatomical site of likely injury, or general and diffuse?
• How does the pt indicate the painful area?
o 1 or 2 fingers pointed at a specific spot often indicates the exact somatic structure that is injured or irritated?
o A pt’s broad flat hands rubbing over large area of the body often indicates referred pain
• How can referred pain be visceral or somatic in origin?
o Visceral pain: originates from visceral dysfunction (generally organs)
o Somatic: originated from somatic dysfunction (generally musculoskeletal)
• How is the trauma or mechanism of injury assessed?
o Trauma or no trauma? Often musculoskeletal pain has no mechanism the pt can identify; st mechanism is easily identifiable major trauma like fall or motor vehicle collision; st mechanism is minor repetitive trauma like keyboard, etc; usually visceral pain won’t have easily identifiable mechanism of injury
• How is the onset of pain assessed?
o Insidious (degenerative or chronic conds) or sudden (infectious, inflammatory, vascular, traumatic conds) onset? o What accompanies the onset? Pain w/ or w/o limitation of movt; have they had the pain before?
• What are provocative and palliating factors in differentiating ms and visceral pain?
o Palliation: ms pain is usually relieved by rest, certain positions, some physical factor (heat, cold, massage, etc); visceral pain is usually not relieved by above
o Provocation: aggravation of ms pain is usually related to (motion, compression, stretch of a structure); aggravation of visceral is often related to stressing the involved organ
• How is quality of visceral and somatic pain assessed?
o Most visceral pathology has pain that is poorly localized, dull, accompanied by autonomic symptoms (diaphoresis, nausea, anxiety, pallor, weakness)
o Somatic pain be (depending on the injured or irritated structure) sharp or dull, well-localized or diffuse, deep or superficial; somatic pain usually doesn’t have autonomic components
• What are 1-5 of the common signs and symptoms of pain with possible causes?
o 1. Pain w/ isometric contraction: muscle being contracted is injured or irritated
o 2. Pain w/ passive stretching: injury to ligs, mm, or tendon; if passive stretching in one direction is painful and active isometric contraction in opp dir is painful, injury is probably muscular/tendinous
o 3. Pain in mm belly w/ direct pressure: trigger pt, tendonitis, or mm strain
o 4. Pain w/ jt distraction, gapping or shearing: articular or lig injury
o Pain in jt w/ compression of jt: cartilaginous injury
• What are 6-10 of the common signs and symptoms of pain with possible causes?
o 6. Painless crepitus: degenerative jt dz (DJD), congenital deformity, mm spasms
o 7. Painful crepitus: DJD
o 8. Tender areas of mm belly w/ referred pain: trigger pts, have consistent referral patterns that are well-documented
o 9. Tenderness directly over jt line: lig injury
o 10. Tenderness at mm origin and insertion: chronically weak mm
• What are 11-15 of the common signs and symptoms of pain with possible causes?
o 11. Chapman’s reflexes that are exquisitely tender, grainy or frankly painful: active Chapman’s reflexes
o 12. Pain (at rest) along a meridian or at its alarm pt: often indicates deficient chi in that channel
o 13. Tenderness (to palpation) along a meridian or at its alarm pt: often indicates excessive chi in that channel
o 14. Pain on either side of a spinous process: probable jt dysfunction at that level
o 15. Tenderness of a mm belly that decreases w/ a passive shortening of the mm: mm strain
• What is the focus of NMT (naturopathic manipulative therapeutic techniques)?
o Skeletal, arthroidal and myofascial structures and the related vascular, lymphatic and neural elements; primary focus is on jt hypomobility; use of several types of manipulation techniques to treat these problems; somatic dysfunctions which are also manipulable lesions; involves tissues that don’t move sufficiently
• What is somatic dysfunction in NMT?
o Impaired or altered function of related components of the somatic (body framework) system
• What is a manipulable lesion in NMT?
o Any impaired or altered aspect of the somatic, visceral, craniosacral or energetic system for which a known manual intervention is indicated to restore “normal” or homeostatic function; assoc w/ pathomechanical (structural) or pathophysiologic (functional) alterations of the neuromuscular system and its jts; the hallmark of a manipulable lesion in somatic system is impaired or altered function has caused hypomobility (or less than optimal movt) of 1+ of components of somatic system
• What is osseous mobilization in NMT?
o Skilled, passive movt of bones/jts designed to restore physiologic motion; performed by practitioner directly moving one or both bony members of a jt in a low velocity, graded manner; designed to stimulate mechanoreceptors, move synovial fluid and stretch the jt capsule
• What is joint manipulation in NMT?
o Performed by using a high velocity, low amp thrust technique which can break adhesions in jt capsule and release endorphins
• What are the benefits of manipulation in NMT?
o Restoration of normal physiologic motion; nourishment of cartilage via movt of synovial fluid; increased circulation of blood and lymph to surrounding tissues via reflex mm relaxation and improved posture and breathing; increased movt of soft tissues including increased mm contraction; mechanoreceptor and proprioceptor reeducation through jt movt; breaking adhesions in jt capsule and ligs; pain control through stimulation of jt movt; release endorphins
• What are 2 indirect manual therapy techniques in NMT?
o Strain/counterstrain (positional release) and induration technique
• What is strain/counterstrain in NMT?
o Indirect method to tx jt dysfunction by easing residual strain in neuromuscular mechanism; indirect b/c doesn’t directly engage a barrier to motion and move against it; practitioner doesn’t NECESSARILY directly touch jt
o passively place body part in position of ease w/ pt relaxed; monitor results of tx, after 90 sec, slowly return to neutral pos; helps reeducate neuromuscular system, relieve somatic dysfunctions and jt dysfunction
• What is induration technique in NMT?
o Positional release, passive; relaxation of paraspinal mm; Ex: gently rotate a vertebra from its SP to release tension in intersegmental mm
• What do direct manual therapy techniques in NMT involve? 2types?
o After identifying a barrier to normal movt, move directly against barrier to restore movt; Ex: T6 is restricted in rot, so practitioner restores rot w/ direct contact at T6
o Muscle energy technique (MET) and Myofascial release (MFR)
• What is muscle energy technique (MET) in NMT? 3 types of contraction?
o Mm contraction and relaxation to move bone and restore alignment/ jt motion; good alternative when contraindications to osseous manipulation (RA or osteoporosis); assists in neuromuscular reeducation; requires specific positioning of pt, often similar to manipulation; pt contracts mm (mm energy) and resists the movt of dr
o Eccentric: contraction while lengthening
o Concentric: contraction while shortening
o Isometric: contractions w/o movt
• What is myofascial release (MFR) in NMT?
o Affects myofascial tissue and neural and vascular structures running through it; dr feels pt’s inherent tissue motion and gives sustained pressure into myofascial restrictions to eliminate pain and restore motion; can free hypomobile jts by reducing tension of myofascial structures associated w/ them
• What are the direct and indirect methods of MFR in NMT?
o Direct: find tissue tension barrier and gently move MF tissue against and through barrier
o Indirect: amplify inherent tissue motion, thus “unwinding” the restrictions
o Often both used in combo
• What do correct musculoskeletal diagnoses depend on?
o Knowledge of functional anatomy; accurate pt hx; diligent observation; thorough exam
• What does a differential diagnosis involve?
o Use of clinical signs and symptoms; PE; knowledge of pathology, mechanism of injury; provocative tests; motion palpation; lab diagnosis; imaging (xray, MRI, CT, etc)
• How is accurate documentation made?
o Problem-oriented medical records; use SOAP notes
o Subjective: pts description and goals
o Objective: exam findings, lab and imaging goals
o Assessment: dx, DDx, problem list, Dr’s opinions, prognosis
o Plan: what you did, plan to do, tx frequency and duration, and referrals, considerations
• What are some general considerations for musculoskeletal assessment?
o Develop a sequential approach to evaluation to avoid overlooking anything; compare findings to normal (opposite) side of pt’s body; compare contralateral ROM; understand variations on normal (eg ROM, mm strength, sensation, etc); stay focused on one task at a time; consider potential compensatory mechanisms
• What are some pts about taking a pt hx?
o Good active listening skills; red flags; pertinent questions; avoid leading pt; use open-ended questions for narrative disclosure; used closed or directed questions for specifics, especially details to clarify answers to open-ended questions
• How is pt age a pertinent question?
o Teens: Legg-Perthes dz and Scheuermann’s dz
o Young adults (15-35): shoulder impingement due to muscle weakness
o Older adults (40+): shoulder impingement due to DJD in shoulder
• How is pts occupation and hobbies a pertinent question?
o Repetitive strain, assembly line work, keyboard overuse, poor postural habits, musicians, athletes, weekend warriors, injury-prone laborers
• Explain pts complaints, mechanism of injury, and predisposing factors as pertinent questions:
o Cc, history of present illness; helps determine pts expectations, whether or not they’re realistic, or you can provide any assistance
o MOI: specific details are important to assess function; direction of traumatic force and magnitude; how force was applied; helps determine type and extent of tissue damage
o Predisposition: general health; state of alertness; state of physical conditioning; genetic problems; familial problems
• Explain onset of injury, timing, provokers, and relievers as pertinent questions:
o Onset: date, if known; insidious; sudden
o Timing: worse in am or pm?
o Provokers: exact movts, postures, activities that cause pain
o Relievers: postures, motions, modalities that diminish pain
• Explain exact location of injury as a pertinent question:
o Pt may pt finger to specific location; flat hand/broad area of concern may indicate potentially more serious injury, referred pain; may use body charts for documentation; note any trigger pts in mm; note at what pt in ROM the pain occurs; note difference b/w passive vs active ROM, if any; is there pain at rest? W/ stretch? w/ mm contraction? Distinguish b/w initial onset vs current complaints
• Progression or digression of pain or symptoms, peripheralization, centralization, pain parameters:
o Peripheralization: when the pain area enlarges or becomes more distal (condition worsening)
o Centralization: the area of pain becomes smaller or more localized as the lesion improves
o Pain parameters: acute (7-10 days); subacute (10 d- 7 wks); chronic (> 7 wks); during PE acute cases may be intolerant of certain procedures, so use careful discretion to avoid additional stress to injured areas
• Quality of pain, type of pain, hx of same/similar cond, any previous tx, has recovery been complete, any concomitant factors, any rhythm to complaints, jt status:
o Type of pain: mechanical (better at rest, worse activity); chronic inflammation and edema (morning pain w/ stiffness, better w/ activity); jt congestion (late-day pain w/ or w/o stiffness); acute inflammation (worse initial motion, no better w/ rest); bone pain, CA or visceral dz (no change w/ rest or activity)
o Concomitant factors: is pain worse w/ menstruation; date of last pelvic exam
o Rhythm to complaints: constant, periodic, episodic; constant pain may be due to chemical irritation, tumors, visceral lesions
o Jt status: any locking or unlocking; twinges, crepitus, instability or lig laxity; buckling (usually due to weak muscles)
• What is the circle concept of instability?
o Injury to structures on one side of a jt that cause instability can, simultaneously, cause injury to structures on opposite side or at other parts of jt; therefore, w/ traumas the entire jt complex needs to be examined
• What are 3 types of concomitants (pertinent questions)?
o Neurological signs and symptoms: asthesia, paresthesia, cognitive changes, vertigo, syncope, etc
o Vascular symptoms: skin pallor, skin brittleness, local hair loss, nail abnormalities, EX: ischemia (vasospasm), complex regional pain syndrome, reflex sympathetic dystrophy (RSD), Raynaud’s syndrome, Volksman’s ischemia
o Systemic illness present: CV dz, DJD, DM, CA, asthma, allergies, etc
• Medication, hx of surgery:
o Medications: consider effects of analgesics, corticosteroids, HCTZ diuretics and beta-blockers
o Surgery: when, where, what condition treated, full recovery?
• What are some things to observe during orthopedics assessment?
o Posture, guarding, bracing, rubbing, sighing, normal alignment, any obvious deformity, structural problem vs. functional, any restrictions in ROM, color temp and texture of skin, is movt available and normal, pts attitude regarding condition (apprehension, restlessness, depression, etc), facial expressions, any scars, any crepitus, symmetry, grimacing
• What are the principles of a PE?
o Be systematic, look for consistent patterns, use caution to avoid aggravations, normal side IS usually tested first, active ROM before passive ROM tests, painful motions performed last to prevent overflow of pain signals to the next motion, determine end-feel w/ caution if active ROM is decreased, assess repeated ROM and strength tests, isometric resistance in neutral first, assess quantity and quality of ROM or ligamentous laxity, inform pt that assessment may exacerbate symptoms, temporarily; dermatomes, myotomes, reflexes, any paresthesias present
• What is a scanning examination?
o Screening of spine and extremities, especially useful to rule out referral symptoms; used more often for non-traumatic symptoms; used when radicular signs w/ or w/o trauma, abnormal patterns or spinal cord signs, suspicion of psychogenic symptoms; should take no more than 5-10 mins; divided into 2 exams: upper and lower limb scan
• What are the upper and lower limb scans in a scanning exam?
o Upper: cervical spine; TMJ; scapula; shoulder complex; arms and hands; assoc thoracic spine exam; assoc rib exam
o Lower: lumbar spine; pelvis; LE to toes
• What is motion testing in PE?
o Does pain or restriction predominate?
o Pain: an acute cond is present requires gentler assess and tx
o Restriction: subacute or chronic cond is present may require more vigorous assess and can tolerate more aggressive tx
• What are active movts in PE?
o Performed by pts voluntary mm activity; combines tests of jt ROM, mm power and control, and pts willingness to perform movt; also called “physiological” movts; physiological “barrier” is end of active ROM; if overpressure applied at physiological barrier by examiner and it doesn’t produce symptoms and end feel is normal, the movt is considered normal and passive ROM may be unnecessary to perform
• What are some things to note in active movts in PE?
o Which movts induce symptoms; amount and quality of symptoms; rhythm of movt and any pain, limitation, unusual or “trick” motions (substitutions) that occur; where in the arc of motion symptoms occur; repeat movts or sustain postures
• What are passive movts in PE?
o Jt motions induced by examiner w/ pt relaxed; also called “anatomical” movts; anatomical barrier is end of passive ROM, slightly greater than active ROM; helps determine hypomobility vs gross jt laxity
• What hypermobile jts susceptible to? Hypomobile?
o Hyper: Lig sprains; jt effusion; chronic pain; recurrent injury; paratenonitis from instability; early osteoarthritis
o Hypo: muscle strains; nerve compression syndromes; paratenonitis from overstress
• What are myofascial and pericapsular hypomobility found in PE?
o Myofascial: also known as “fascial restriction”; results from adaptive shortening, hypertonicity of mm, posttraumatic adhesions, scarring
o Pericapsular: originates from ligs or jt capsule; multidirectional restrictions; may be due to adhesions, scarring, arthritis, fibrosis, tissue adaptation
• What is end-feel in PE?
o Sensation the examiner feels at the end of passive ROM; helps asses type of pathology, severity or stage of problem, prognosis for cond; avoid testing or use extreme care if pt has severe pain at end rage
• What are the three classical normal end-feel types?
o Bone-on-bone: (ex: elbow extension); “hard”, unyielding, painless
o Soft-tissue approximation: (ex: elbow or knee flexion); “mushy”, yielding, movt stopped by soft tissue compression, varies w/ muscle size
o Tissue stretch: (ex: knee ext, shoulder external rot); “springy”, elastic resistance, firm w/ a slight “give”, most common type of normal end-feel; capsule or lig primary end-feel; varies depending on tissue thickness
• What are the 5 classic abnormal end-feel types?
o Commonly associated w/ pain or restricted movt
o Muscle spasm: invoked by movt, w/ sudden stop often w/ pain; sudden and hard end-feel; “early” occurs at initiation of motion, assoc w/ inflame, more acute; “late” at/near end of motion, usuallydue to instability or resulting irritability from motion
o Capsular pattern: similar to tissue stretch, but decreased ROM; “soft” assoc w/ synovitis or soft-tissue edema; “hard” has “thicker” feel, seen in chronic conds or full blown capsular patterns like adhesive capsulitis at glenohumeral jt
o Bone-on-bone: osteophytes restricting ROM; similar to normal bob ef, but restricted b4 end of ROM or at unexpected part of ROM
o Empty: acute subacromial bursitis or tumor in or near moving jt; detected when considerable pain is produced by movt; movt eith cant be performed or is stopped due to pain w/ no real mechanical resistance or muscle spasm evident
o Springy block: torn knee meniscus; occurs mostly in jts w/ menisci, often indicating derangement; similar to tissue stretch ef, but generally occurs at unexpected part of jt motion; rebound effect w/ thick stretching feel, but less stretchy than a hard capsular feel
• Generally, what are resisted isometric movts?
o Tested last in jt exams; involves a strong, static, voluntary muscle contraction in a neutral or resting position; used primarily to determine in contractile tissue is involved in pathology; also tests innervation to muscle; grade mm strength on 0-5 scale
o Testing done in rest position or optimum mm length so max force is applied; if pathology causes mm lengthening or shortening, may be mm weakness at neutral, so must test in various positions; differentiates b/w pathological and positional weakness
• What are some things an examiner should note in resisted isometric movts?
o Whether contraction causes pain, note pain intensity and quality; strength of contraction; type of contraction causing pain (concentric, isometric, eccentric)
• What may cause weak contractions in resisted isometric movts? Add’l reasons?
o Pain/reflex inhibition; mm or tendon pathology; avulsion; disuse; nerve root lesion (myotome); peripheral n injury; upper motor neuron lesion
o Fear, unwillingness, malingering, may resolve confusion by testing the uninvolved side first
• What does contractile tissue consist of?
o Mm; tendons; attachments (bone); n tissue that supplies above structures
• What are the 4 classic patterns of contractile lesions upon resistance?
o Strong and pain free: no lesion of mm or nerve present
o Strong and painful: local lesion of mm or tendon
o Weak and painful: severe lesion around jt (eg fracture)
o Weak and pain free: mm or tendon rupture (3rd d strain) or involvement of peripheral n or n root supplying mm
• Generally, what is a functional assessment?
o Helps establish pt’s expectations; measure whole-body performance vs. isolated movts; show whether impairment affects ADLs; may have task analysis, observation of activities, detailed evaluation; may have testing or sport specificity
• What 6 things should be considered in a functional assessment?
o Load, speed, repetition, sustained postures; complexity of movt; degree and severity of functional limitation
• What are some functional activities that should be tested, if appropriate?
o Walking; dressing; daily hygiene; eating and meal preparation; eliminating; reading; dialing phone, etc
• What are the 5 types of special tests in PE?
o Clinical accessory; provocative; motion; palpation; structural
• What are the principles of special tests?
o Strongly suggestive of a particular cond when positive; don’t necessarily rule out dz when neg; st questionable test reliability and validity; dependent on skill of examiner and ability to relax pt; integral part of entire exam
• What are some things to consider while performing special tests?
o Avoid provoking too much discomfort; may be contraindicated or too uncomfortable to perform some tests; avoid over-testing, esp w/ redundant tests (ef if there’s a (+) Turyn’s, no need to perform Sicard’s, SLR w/ great toe extension, b/c Turyn’s is more sensitive; inability to perform test due to pain may assist in dx
• What are some special lab tests used in orthopedics?
o CBC, ESR, ANA, RA factor, Calcium, Thyroid, Parathyroid, more…
• What are reflex and cutaneous distribution tests?
o Use if suspect abnormalities in neurological function; help clarify type of problem; specifically locate lesion
• What are deep tendon reflexes?
o Most often done w/ reflex hammer; graded on scale 0-4; abnormal DTRs clinically relevant usually only when assoc w/ sensory or motor loss; Jendrassik Maneuver used to accentuate minimally active reflexes
• What are superficial reflexes?
o Provoked by stroking skin w/ a mod sharp object w/o harm;
• What is the plantar superficial reflex? Normal and Abnormal response?
o Elicited by stroking lateral side of foot and moving medially over metatarsal heads
o Normal: flex toes; indicates normal S1-S2 function
o Abnormal: 1st toe extension and 2-5 fan out; indicates either pyramidal tract lesion or hemiplegia
• What is a sensory scanning exam?
o Used to determine extent of sensory (skin) loss; can differentiate n root lesion from peripheral n lesions or compressive tunnel syndromes; used to assess degree of functional impairment which is often tied to sensation; can help determine n root recovery as sensation returns b4 motor function; helps determine timing of motor reeducation
• What are some things to note during palpation?
o Differences in tissue tension, texture, thickness; abnormalities; tenderness (scale 0-4); temp variation; pulses, tremors, fasciculations; pathological state of tissue; dryness or excessive moisture; abnormal sensation
• How is diagnostic imaging used in orthopedics? Examples?
o Confirm clinical opinion and establish definitive diagnosis; should be viewed as only one part of assessment
o Plain film radiography (x-ray); arthrography; computed tomography; CT-Arthrography; venogram; arteriogram; myelography; radionuclide scanning; discography; MRI; fluoroscopy; diagnostic US; xeroradiography
• During 2/3 of stance phase, opposite leg is doing what?
o In swing phase
• What is double stance or double support?
o Period when both feet are touching the ground
• What happens in running or increased speed?
o Double support is lost, and both feet are momentarily off ground
• How is the stance phase further broken down?
o Into critical incidents followed by a period o 1. Heel strike -> heel strike o 2. Foot flat -> mid stance o 3. Heel off -> push off o 4. Toe off
• How is the swing phase further broken down?
o Critical incident followed by a period
o 1. Toe off -> acceleration; initial swing
o 2. Toe clearance-> mid swing
o 3. Heel strike -> deceleration
• What is the purpose of pelvic tilt, pelvic rotation, lateral shift, knee flexion, and knee, foot, and ankle motion?
o Minimize shift of center of gravity in both vertical and horizontal axis= conservation of energy during normal gait
• What happens with any interference with normal motions, such as imposed by brace or arthritic jt?
o Result in increased energy expenditure
What is abnormal gait often called?
o Limp, although not all are the same
• When are many gait abnormalities noted?
o In stance phase, b/c it’s when whole body weight is supported on leg; and it’s when pain, mm weakness and jt abnormalities produce their predominant effect
• What is antalgic gait?
o Antalgia=against pain; stance phase is decreased to get weight off affected leg (swing of normal leg is short), so good foot is on floor longer (affected leg relieved of weight bearing)
o Not specific for any pathology; may only represent pebble in shoe, etc; pain in any portion of leg increased w/ walking generally leads to antalgic gait
What are the main pathological conditions that give rise to abnormal gait?
o Pain; weakness, jt abnormalities
• What is the best way to analyze abnormal gait?
o Begin and end with heel-strike
• What are the stance phase gait abnormalities?
o Heel strike; quadriceps weakness; foot slap; back knee; abductor lurch (gluteus medius); Trendelenberg; gluteus maximus; flat foot (calcaneal)
• What is an abnormal heel strike gait?
o Caused by heel pain (w/ contact pressure); pt may avoid hs altogether, and hop onto mid and forefoot
What is quadriceps weakness abnormal gait?
o Knee is normally fully extended at heel-strike; here, pt can’t maintain extended knee; pt may attempt to push one thigh to extend and lock knee
• What is foot slap abnormal gait?
o Weakness of foot and ankle dorsiflexors allows foot to slap on ground (normally dorsiflexors are controlled into relaxation)
• What is back knee abnormal gait?
o Fixed plantar flexion deformity of ankle, affecting mid stance; recurvatum at knee to accommodate forward motion of trunk and pelvis during mid-stance=hyperextension of knee, due to weak quadriceps, in order to lock knee, prevent from buckling or going into excessive flexion (mid stance is usually maintained in slightly flexed position)
What is abductor lurch (gluteus medius gait)?
o Abductors about hip on stance leg must contract to prevent opp pelvis from tilting down excessively; increases pressure across hip jt to more than just body wt; may result in pain and pathology about hip; = center of gravity is shifted over hip jt, balance weight on top of ball of femoral head (=lateral shift of trunk > 1 in); weakness of glut med activity (polio or L5 n root lesion) is another cause
• What is a Trendelenberg gait?
o Like abductor lurch, but w/o pain; pelvis on swing side sink excessively (rather than excessive lateral shift seen in abductor lurch)
What is gluteus maximus abnormal gait?
o Weakness of glut max, pt thrusts trunk posteriorly, resulting in extensor lurch (glut max gait); normally in mid stance hip is in extension or trunk would collapse forward
• What is flat foot or calcaneal gait?
o Abnormal push off, due to pain or rigidity in forefoot; toes are not bent, rather entire flat foot is lifted up in swing; may also be due to weak calves (inability ot push off properly)
• What are the swing phase abnormal gaits?
o Steppage (drop foot); hip-hike; circumduction; abnormal pelvic rotation; wide based
• What is steppage or drop foot gait?
o Total paralysis of foot and ankle dorsiflexors, leg is brought up higher off ground than normal by flexing hip and knee, so toes can clear ground
• What is hip-hike abnormal gait?
o Pt w/ drop foot or stiff knee, may hike hip so foot clears floor
• What is circumduction abnormal gait?
To overcome hip-hike or steppage gait; swings leg out to side to clear foot
• What is abnormal pelvic rotation?
o Weak hip flexors of swing leg doesn’t allow adequate acceleration; to compensate, excessive forward pelvic rotation
o Fused hip on stance side doesn’t allow normal forward pelvic rotation on swing leg, so step length of swing leg is limited
• What is a wide based gait?
o Due to imbalance, legs are spread far apart; causes excessive shift in center of gravity and excessive energy expenditure
