Final Lecture Exam Flashcards
Describe Grade I sprain
Stretching, small tears <50%
Describe Grade II sprain
Larger but incomplete tear >50% tear
Describe Grade III sprain
Complete tear, no end point, significant laxity
Describe Grade I sprain/strain laxity and end point
Mild laxity
Stable end point
Describe Grade II sprain/strain laxity and end point
Moderate laxity
Soft end point
Describe Grade III sprain/strain laxity and end point
Significant laxity
No end point
Describe Grade IV sprain/strain
Complete tear
Detachment of muscle or ligament from the bone
Ecchymosis
discoloration of the skin resulting from bleeding underneath, typically caused by bruising.
Difficulty bearing weight Grade I vs II vs III
I - no difficulty
II - usually have difficulty
III - almost always have difficulty
How many weeks to return to full activity after Grade I sprain?
2-4
How many weeks to return to full activity after Grade II sprain?
6-8 weeks
How many weeks to return to full activity after Grade III sprain?
12 weeks to 6 months
Phase I in the healing process is called
Inflammatory (acute)
Phase 1 lasts how long
48-72 hours
Key to controlling phase 1 is
Controlling inflammation
Acute signs of inflammation = S.H.A.R.P.
Swelling Healing A loss of function Redness Pain
The second phase of injury is called
Repair (subacute)
How long is the repair/subacute phase?
72 to 6+ weeks
The third phase is called
Remodeling (chronic)
Remodeling (chronic) phase timeline
6 weeks - 2 years
What is the goal for phase 1: inflammatory (acute)?
Control inflammation
Reduce swelling and pain
What is the goal for phase 2.1: repair (subacute)?
Regain tensile (functional) strength
What assessments and/or treatments that we’ve done in class are appropriate for stage 2.2: repair (late subacute)?
Friction techniques / Instrument assisted soft tissue massage (IASTM)
Isometrics: METs (both RI and PIR with gentle stretching)
Can work directly at site with caution to not overly stress new tissues
What is the goal for phase 3: remodeling (chronic)?
Redirect healing fibers to increase strength and orient the tissue fibers along lines of greatest stress
What assessments and/or treatments that we’ve done in class are appropriate for stage 1: inflammatory (acute)?
Myofascial trigger point work for those that refer to injury site but NOT the acute site
Muscle Energy Techniques without stretching. RI is idea and PIR with pain-free contraction only
NO Key Movement Patterns
Evaluate breathing patterns
McGill’s Big 3: quadruped, dead bug, side bridge
What assessments and/or treatments that we’ve done in class are appropriate for stage 2: repair (subacute)?
Similar to acute stage, but now tissue adjacent to injury can be carefully addressed
Cross fiber, not longitudinal though
Be careful with distal treatment (e.g. working on the wrist if the elbow is injured)
Contrast hydrotherapy: alternating hot 2 mins and cold 1 min, repeat
What assessments and/or treatments that we’ve done in class are appropriate for stage 3: remodeling (chronic)?
Evaluate key movement patterns
Scar tissue reaches maximum stretch, often still only 70-80% of original tissue strength
ROM and strength
Stabilization tracks: quadruped, dead bug, bridge
What are the goals of soft tissue manipulation (8)?
- Mobilization of fluids/reduction of edema
- Increase of local blood flow
- Decrease muscle soreness/stiffness
and ↑ ROM - Prevention or elimination of
adhesions - Reduction of pain
- Eliminate Myofascial Trigger Points
(MFTP) - Facilitation of relaxation, reduction
of spasm, hypertonicity and/or
overactivity - Restore balance to motion segment
What are contraindications for soft tissue manipulation?
- Acute inflammation, osteitis, periostitis
- Acute circulator ydisturbance
- Acute dermatological problem
- Fever (systemic)
- Local infection
- Local malignancy
- New burns
- Potential embolus/thrombus, varicosities
- Abdominal tumor, aneurysm
What are the 8 parts to low back rehab program?
- Neutral pelvis, abdominal bracing, hip hinging
- Directional preference
- Posture and breath training
- Return to activity
- Floor exercises to reprogram stability
- Weight-bearing exercises
- Balance large global muscles
- Proprioceptive/balance training
Why is hip hinging taught?
To avoid end-range loading during ADLs
Why is posture/breath training taught?
Address inefficient posture and breathing patterns
Why are floor exercises taught?
To work pts physiological corset
What are the 4 trunk postural muscles?
- Cervical and lumbar erectors
- Quadratics lumborum
- Scalenes muscles
- Sternocleidomastoid m
What are the 4 shoulder postural muscles?
- Pec major and minor
- Levator scapula
- Upper trapezius
- Bicep brachii
What are the 2 trunk phasic muscles?
- Mid thoracic erectors
2. Longus capitus and colli
What are the 4 shoulder girdle phasic muscles?
- Rhomboids
- Middle trapezius
- Lower trapezius
- Triceps brachii
What will the brain do when agonist muscle is firing?
Turn off tone to antagonist muscle
In upper crossed syndrome, what muscles are inhibited/weak?
Phasic muscles:
Cervical flexors
Rhomboids, lower traps
In upper crossed syndrome, which muscles are tight?
Postural:
Suboccipitals, upper trap, Levator scapula
Pectorals
What are common postural findings for upper crossed syndrome??
- Anterior head carriage (chin jut)
- Forward and rounded shoulders
- Internally rotated humerus
- Thoracic hyperkyphosis
- Protruding abdomen
Which key movement patterns evaluate muscles involved in upper crossed syndrome?
Neck flexion
Trunk flexion
Shoulder abduction
Lowering from push-up with a plus
Which muscles are weak/inhibited in lower crossed syndrome?
Phasic:
Glut max
Abdominals
Which muscles are tight in lower crossed syndrome?
Postural:
Erector spinae
TFL, QL
Iliopsoas, Rectus femoris
What are common postural findings for lower crossed syndrome?
PELVIS: A/P tilt, torsion, hiking, lateral shift
GLUT MAX: flattened upper-outer quadrant, sagging fold
ADDUCTORS: distal “notch” ipsilateral hip dysfunction
HAMSTRINGS: overactivity in distal 1/3 = inhibited glut
CALF: soleus hypertrophy
LUMBAR ERECTORS: should be > TL erectors
What key movement patterns evaluate lower crossed syndrome?
Hip extension
Hip abduction
Trunk flexion
What are McGill’s “big 3” exercises?
Quadruped
Dead bug/curl-up
Side bridge
What stabilization exercises train glut max?
Quadruped
Prone
Bridge
What stabilization exercises train glut med?
Side-bridge
Side-lying
Single-leg bridge
What stabilization exercises train scapula stabilizers?
Quadruped
Prone
What stabilization exercises train abdominals?
Curl-up
Dead bug
Side-bridge
What stabilization exercises train neck?
Quadruped
Is dry needling allows under Oregon’s DC scope of practice?
Nope
What aggravates trigger points (6)?
- Strenuous use of the muscle (especially in a
shortened position) - Quick stretching of the muscle
- Direct pressure on the MFTP
- Holding the muscle in a prolonged shortened position (often after being in bed or sitting for a while)
- Sustained or repeated contractions
- Exposure to cold draft (especially if the muscle is fatigued)
Essential criteria to diagnose trigger point (3)?
- Tender nodule within muscle or tendon
- Predictable pattern of referred pain with palpation
- Painful limited ROM
What are trigger point perpetuating factors that are biomechanical (4)?
- Postural dysfunction
- Hyperventilation tendencies
- Hypertonicity
- Neural compression
What are psychosocial reasons for perpetuating trigger points (2)?
- Stress
- Hyperventilation
What are biochemical reasons for trigger points perpetuating (4)?
- Nutrition
- Ischemia
- Inflammation
- Hyperventilation
How do you find a trigger point (4)?
- Palpate across the fibers to locat taut band
- Search within band for nodule
- Apply NIMMO or travell
- Communicate with pt to work around 5-7 on the pain scale
What are (4) steps for trigger points using NIMMO?
- Muscle relaxed
- Apply pressure for 3-7 seconds
- Repeat until improved or up to 5 minutes
What are (4) steps for trigger points using Travell?
- Stretch muscle
- 20# pressure for 10-60 sec
- Repeat until improved or up to 5 minutes
Other trigger point treatment?
- Chaitow: like Travell, but 5 seconds on and 2 seconds off for 20-30 seconds
- PIR
- Percussion
- Dry needling or TP injection
- High-power pain threshold ultrasound
Hypertonic muscles need vs tight muscle needs
Hypertonic: needs to relax
Tight: needs to stretch
Note: Tight muscle is like a leather belt
What is the end range feel for hypertonic muscle?
Supple; but muscle cannot lengthen to expected length
What is the end range feel for tight muscle?
harder, fibrotic, less resilient due to chronic shortening
Explain the stretch reflex in hypertonic muscle:
More sensitive and engaged sooner
What is a hypertonic muscle?
Physiologic condition in which excitability threshold is increased, resulting in increased resistance to lengthening
What kind of problem is a tight muscle?
Facial or noncontractile problem
What is central sensitization?
Long-lasting, increased excitability changes in spinal cord low
back wide dynamic range neurons caused by nociceptive
stimulation of low back tissues
What is the body’s response of central sensitization (4)?
- Increased ongoing impulse discharge
- Increased responsiveness to previously effective peripheral stimuli (hyperalgesia)
- The appearance of responses to previously ineffective somatosensory stimuli (allodynia)
- The appearance of responses to stimulation outside of the zone
that previously evoked responses (i.e., receptive field enlargement
or expansion)
How does muscle energy technique affect central sensitization?
Phasic and tonic inhibitory processes hyperpolarize already sensitized low back wide dynamic range neurons
For MET how is force applied in acute vs chronic patient?
Acute: at a “resistance barrier”
Chronic: short of resistance barrier
Resistance barrier refers to
Very first indication of palpation tension or resistance to free movement in a direction
What are indications for Reciprocal Inhibition (RI) - antagonist
- Restricted joints
- Preparing joint for manipulation
- Short and tight muscle
- Muscle stretching when contraction of agonist is undesirable
What are indications for Post Isometric Relaxation (PIR) - Agonish
- restricted joints
- preparing joint for manipulation
- short and tight muscle
What are the 4 steps of RI - Antagonist?
- Antagonist contracts isometrically 6-10 secs
- Complete relaxation 5 secs
- Passive stretch: take tissue passively to new barrier and beyond
- Hold new stretch 30-60 secs
Repeat 3-5 times
Note: this is exactly the same as PIR with the exception of step 1: agonist/antagonist isometric contraction
Where do RI and PIR both start?
Short of first restriction barrier
What are the (4) steps for PIR - agonist
- Agonist contracts isometrically 6-10 secs
- Complete relaxation 5 secs
- Tissue taken passively to new barrier and beyond
- Hold new stretch 30-60 secs
Repeat 3-5 times
Note: this is exactly the same as RI with the exception of step 1: agonist/antagonist isometric contraction
In both PIR and RI, what do you do differently post-contraction between acute and chronic patient?
Acute — gentle lengthening to new barrier on exhalation (because the function is to relax)
Chronic — rest 5 seconds. Gentle lengthening to new barrier and slightly beyond on exhalation. Engage patient assistance. Hold 30-60 sec (because function is to stretch)
A post-facilitation stretch is for which muscle (antagonist or agonist)?
Agonist
When is post-facilitation stretch indicated?
Stretching chronic restricted, fibrotic, contracted soft tissue
What are the 5 steps for post-facilitation stretch - agonist?
- Contraction initiation from midrange
- Pt contracts at/near 100% — hold 6-10 secs
- Pt relaxes muscle as quickly as possible
- Dr aggressively stretches muscle — hold 15 secs
- Relax in midrange up to 30 secs
What are the 6 steps of Contract-Relax Antagonist Contract (CRAC)?
- Pt actively stretches tissue to barrier
- Dr supports this position
- Pt isometrically contracts agonist against Dr support — 10-20 secs
- Pt uses antagonist to find new barrier
- Dr supports new position
Repeat #3-#5 … 3-5 times
- Pt isometrically contracts agonist against Dr support — 10-20 secs, relax
What is isolytic lengthening?
When a muscle contracts while external forces cause it to lengthen
If postural stability is required during aerobic challenge AND physiologic demand for O2 is high, what will the nervous system prioritize?
Respiration over spinal stability
When breathing becomes labored, what happens to the abs?
Abs are inhibited to maintain respiration
What are 2 common 1˚ respiratory faults?
- Apical breathing or upper chest breathing
2. Paradoxical breathing when abdomen moves “in” during inhalation and “out” during exhalation
What are 7 commong 2˚ respiratory faults?
- Breathing is shallow with little motion in abdomen or rib cage
- Asymmetrical motion in abdomen or rib cage
- Sequence from abdomen to chest is altered
- Rhythm is abrupt or “over-effort is seen”
- Inhalation and expiration are rapid or uneven in duration
- Excess tension seen in face, lips, jaw, tongue
- Frequent sighing or yawning
What are the 3 parts of breathing assessment?
1 - movement should initiate in abdomen
2 - lower ribcage widens in horizontal plan
3 - upper ribs fan open
Breathing assessment can be performed in these 5 positions:
Seated Standing Supine Prone In functional activities
List the 3 steps of external TMJ muscle palpation technique
- Palpate all 3 bellies of temporalis
- Palpate masseter S-I
- Palpate inferior aspect medial pterygoid
Note: palpate all mm while relaxed and while teeth clench
List the 3 steps of internal TMJ muscle palpation technique for Masseter
- Begin at outer edge of lower teeth — 1 finger inside cheek and several on the outside
- Palpate proximal to inferior edge of coronoid process
- Have Pt clench to capture bulk of mm
List the 2 internal palpation steps to move from Masseter to Temporalis Tendon
- release masseter (from previous step)
2. travel up coronoid process to insertion of temporalis tendon
How would you internally palpate Lateral Pterygoid (pretend you just finished palpating the temporalis tendon)
Probe superiorly, posteriorly, medially in the pocket between teeth and cheek — Pt can shift mandible side to side
How would you palpate the medial pterygoid (after the lateral)
Finger on the inside edge of lower teeth: palpate as it travels down the angle of the mandible
The body’s initial reaction to musculoskeletal injury is often
Over reaction
Inflammatory responses of tissues to injury are nonspecific to their etiology and the process is generally conceded to be excessive for those of traumatic or mechanical musculoskeletal origin
The body’s overreaction to musculoskeletal injury can lead to
Excessive collagen formation and fibrosis
What are 5 indications to use transverse friction soft tissue manipulation (STM)?
- Recent/old trauma to muscle, tendon, ligament
- Injury/degeneration changes at myotendinous junction
- Acute/chronic tendon itis, tenosynovitis, tenovaginitis
- Ligamentous sprains, recent and chronic
- Chronic bursitis (NOT ACUTE)
What are 6 contraindications to Transverse friction STM?
- Bacterial infections
- Traumatic arthritis
- RA and tendinitis
- Acute bursitis (chronic is OK)
- Over superficial nerves
- Those common to all soft tissue treatment: acute inflammation, hematoma, calcification, decreased vascularity, local sepsis, local skin disease
Gua Sha
Coin rubbing
4 Indications to use longitudinal soft tissue manipulation
- Any abnormality of the body may warrant gua sha
- Pain anywhere may warrant gua sha, acute or chronic
- When finger pressure on skin causes blanching that is slow to fade,
sha (stasis) may be suspected. - May treat or prevent acute conditions (e.g., common cold, flu,
asthma, bronchitis) or chronic problems involving pain or congestion of the qi and blood.
4 contraindications to use longitudinal soft tissue manipulation
- Acute traumatic bruising or abrasion
- Sunburn, rash, pimple, mole or break in skin
- Pregnant abdomen, deficient patients
- Bleeding disorders
Isolytic lengthening is thought to (3):
Promote orientation of collagen fibers along lines of stress and direction of movement
Limit infiltration of cross bridges between collagen fibers
Prevent excessive collagen formation preventing any muscle stiffness
Postural muscles are what kind of muscle fibers?
Type 1
Tendency to shorted and tighten when chronically stressed and/or injured
Phasic muscles are what type of muscle fibers?
Type 2
Burn out quickly and tend to lengthen and weaken
If SCM is short and tight and rhomboids are long and weak, what would you do?
RI technique for rhomboids to get shoulder girdle back into position
Tight psoas?
RI on psoas will activate it and lengthen postural muscles
Open kinetic chain vs closed kinetic chain
Open: distal segment is not fixed
Active vs latent trigger point?
Active: produces symptoms
Latent: does not trigger pain until someone pokes at it
“Key” vs “Satellite” Trigger point
Key: when treated, decreases activity in satellites
Satellite: when treated, usually does not decrease key activity or pain — its more a compensation trigger point
What is the diagnostic criteria for trigger points (3)?
- reproduction of pain
- jump sign
- local twitch response with snapping palpation
Note: #1 and #2 is not sufficient for diagnosis
