Foundations of Musculoskeletal Practice

Question 1

What does SAC stand for

Answer 1

• Screen: red/yellow flags, neuro screen, & movement screen
• Acuity: how vigorous can the physical exam be (SINSS)
• Classification: diagnosis for treatment, CPG’s

Question 2

What are the types of referrals

Answer 2

• Emergent referral: immediate termination of exam & send patient to hospital/ED
• Urgent referral: immediate termination of exam & have patient see specialist within the next couple of days
• Watchful Waiting: continue with exam & treatment but make patient aware of signs/symptoms to look out for
• Treat: all is well treat as normal
• Self-care Management

Question 3

What are some general pain related red flags that could possibly be a serious pathology

Answer 3

• Uncontrolled with analgesics
• Not reproduced/exacerbated by your evaluation
• Worsens at night or with rest
• Exacerbates with general activity
• Bilateral
• Encompasses several dermatomes

Question 4

What are the 9 “Do not want to miss” serious pathologies

Answer 4

• Major depression
• Suicide risk
• Femoral head & neck fractures
• Cauda Equina Syndrome
• Cervical myelopathy
• AAA (abdominal aortic aneurysm)
• DVT (deep vein thrombosis)
• PE (pulmonary embolism)
• Atypical MI (myocardial infarction)

Question 5

What is the first question for any new initial exam

Answer 5

• Is the patient appropriate/right for PT

Question 6

Good tools to screen for yellow flags

Answer 6

• High fear avoidance
• High pain catastrophization
• Presence of central sensitization

Question 7

What are some yellow flags that can be discovered from the interview

Answer 7

• Passive attitude
• Extended rest
• Family enablement
• Lack of financial incentive to return to work
• High intake of other substances

Question 8

Define yellow flags

Answer 8

• Psychosocial indicators suggesting an increased risk of progression to long term distress, disability, & potential drug misuse
• Includes patient’s attitudes, beliefs, emotions, behaviors, & family and work place factors

Question 9

What does SINSS stand for

Answer 9

• Severity: what level (intensity)
• Irritability: how high, quick, & how long (intensity/quality), amount of activity to stir up symptoms
• Nature: Aggies & eases (location/MOI), hypothesis of structures involved
• Stage: acute, sub-acute, chronic (temporal characteristics)
• Stability: symptom behavior over time (temporal characteristics), getting better or getting worse

Question 10

What are the 3 basic mechanisms of injury (MOI)

Answer 10

• Acute trauma
• Repetitive overload
• Insidious/Unknown

Question 11

Describe the levels of acuity

Answer 11

• Low: all systems go
• Medium: proceed with caution; intense, sharp pain that is brief
• High: lots of caution and pain with next steps of exam

Question 12

Describe mobility

Answer 12

• Consistent: same ROM limit in ANY position & across activities
• AROM > PROM: end feel = tight, springy, block
• Tissue extensibility dysfunction (TED): scarring & fibrosis, neural tension, fascial tension, muscle shortening, hypertrophy
• Joint mobility dysfunction (JMD): OA, osteoarthritis, dislocation, fusion, adhesive capsulitis, subluxation
• Accessory Joint Glide: hypomobile/restricted

Question 13

Describe stability

Answer 13

• Inconsistent: change of position improves ROM limits; some activities OK
• PROM > AROM: end feel= empty or pain restricted
• Stability & motor control dysfunction (SMCD): True stabilization is reflex driven & relies on proprioception & timing; Compensatory patterns create pseudo-stabilization
• Accessory Joint Glide: Normal L to R

Question 14

Define high threshold strategy for stability

Answer 14

• Use global muscles to accomplish tasks more suited to local muscles as a result of pain, previous injury, or chronic dysfunction

Question 15

What are the phases of healing (exercise prescription framework)

Answer 15

• Tissue healing
• Mobility
• Stability & motor control
• Performance improvement
• Advanced skill, agility, & coordination

Question 16

What are the tissue healing phases

Answer 16

• Protection
• Remodeling
• Repair

Question 17

What are the 3 rehab approaches using provisional classification

Answer 17

• Symptom modulation
• Movement control
• Functional optimization

Question 18

Exercise prescription framework + rehab approach to choose interventions

Answer 18

• Symptom modulation = tissue healing & mobility
• Movement control = mobility & stability and motor control & performance improvement
• Functional optimization = performance improvement & advanced skill, agility, and coordination

Question 19

Interventions based on symptom modulation rehab approach

Answer 19

• Modalities (C-traction)
• Education
• Relative rest/controlled exercise
• Joint & soft tissue mobilization/HVLA
• McKenzie
• Mulligan
• PNE (pain neuroscience education) *if signs of chronic

Question 20

Interventions based on movement control rehab approach

Answer 20

• <Modalities
• Education
• Sensorimotor (activation-Acquisition), Stabilization, Flexibility (loading)
• <Joint & soft tissue mobilization (self)
• <McKenzie
• <Mulligan
• PNE (pain neuroscience education) *if signs of chronic

Question 21

Interventions based on functional optimization rehab approach

Answer 21

• No Mo, No Modalities
• Education (Prevention)
• Assimilation: LOADING for return to work &/or sport
• Fitness
• Endurance
• PNE (pain neuroscience education) *if signs of chronic

Question 22

Describe the tissue differentiation classification

Answer 22

• Functional & non-painful
• Contractile tissue: AROM and PROM limited or painful in opposite directions
• Inert tissue: AROM and PROM limited or painful in the same direction
• Motor control: stability; AROM limited and PROM improves slightly

Question 23

What are considered body functions in the IFC model

Answer 23

• Think of as “what it does”
• Ex: sensory, pain, mental, voice, or speech functions

Question 24

What are considered activities & participation in the ICF model

Answer 24

• Ex: Learning and applying knowledge, General tasks and demands, Communication, Mobility, Self-care, Domestic life, Interpersonal interactions and relationships, Major life areas, Community, social and civic life

Question 25

What are considered environmental factors in the ICF model

Answer 25

• Ex: Products and technology, Natural environment and human-made changes to environment, Support and relationships, Attitudes, Services, systems and policies

Question 26

What are some appropriate, inappropriate, and preventable reasons for cervical spine manipulations

Answer 26

• Appropriate: Neck pain, neck stiffness, HA, or cervical radiculopathy
• Inappropriate: low back pain, otitis media, asthma, non-radicular shoulder pain
• Preventable reasons: C-spine pathology RA, osteoporosis, spondylosis, vascular cardiac & atherosclerosis

Question 27

Risks and benefits of orthopedic manipulative therapy of the neck

Answer 27

• Risks: very low absolute risk 0.006%, less risk compared to alternative Tx from NSAIDS and analgesics 6%
• Benefits: moderate to large effect sizes for neck pain, disability, functional outcomes, cervical radiculopathy, favorable outcomes for tension type HA, & adding OMT to exercise enhances effect

Question 28

Slide 13 wait 48 hours to a week to manipulate the cervical spine if showing these signs

Question 29

What are the DAN’s (5Ds, 2As, and 3Ns)

Answer 29

• 5D’s: dizziness, diplopia, drop attacks, dysarthria (hoarseness and hiccups), dysphagia
• 2A’s: ataxia of gait and anxiety
• 3N’s: nausea, numbness (ipsilateral face and/or contralateral body), and nystagmus

Question 30

C-spine subjective red flags

Answer 30

• Trauma (MVA or other consider C-spine x-ray rules/ACR)
• Report of the DANs even if transient (lasts for a short time)
• Sudden onset in the absence of trauma described as unlike any other
• Transient or current Horner’s syndrome
• Patient history of cardiac risks and/or tobacco use

Question 31

Canadian C-spine rules for high risk factors that mandate radiograph

Answer 31

• Any of the below positive then X-ray
• Age >65
• Dangerous MOI: fall from >1 meter/5stairs, axial load to head, VMA high speed/rollover/ejection, motorized recreational vehicle
• Parathesias in the extremities

Question 32

Canadian C-spine rules for low risk factors to see in need X-ray

Answer 32

• If OK with the below then are they able to actively rotate neck 45º L/R: if yess then NO x-ray needed)
• Simple rearer-end MVC
• Sitting position in ED
• Ambulatory at any time
• Delayed onset of neck pain
• No midline C-spine tenderness

Question 33

Slide 23

Question 34

Glasgow coma scale

Question 35

Signs of a skull fracturer

Answer 35

• Raccoon eyes: bruises around the eyes/eye bag area
• Battle’s sign: bruise on/near the mastoid right behind the ear

Question 36

4 tier remobilization screening process for the cervical spine

Answer 36

• Historical review: PMH, MOI
• Medical testing and diagnostic imaging
• Clinical screening for segmental stability: upper ligamentous testing, stress testing
• Clinical screening for VBI: rotation 1st, rotation and extension 2nd (deKleyn’s test), and pre-manipulation positional hold

Question 37

Testing for hypoglossal nerve (CN XII)

Answer 37

• Stick out tongue
• Strength test resist into cheek

Question 38

Testing for glossopharyngeal (CN IX)

Answer 38

• Difficulty swallowing
• Gag reflex

Question 39

Testing for vagus (CN X) and accessory (CN XI)

Answer 39

• Say Ahhhhh (CN X) or hoarseness/poor cough (CN XI)
• Or Horner’s syndrome: Ptosis (drooping eyelid), Mitosis (pupil constriction), and Anhydris of the face (dryness)

Question 40

Screening for osseous/ligamentous serious pathology in the c-spine

Answer 40

• Fracture: Jefferson (C1), DENS (C2), lamina, or burst fracture (vertebral body)
• Ligamentous disruption: Alar or Transverse ligament
• Clues from history: any trauma (object size and force) - fall, MVC, sports HIT
• Conditions that weaken the system: RA, osteoporosis, long steroid use, Down syndrome, Arnold Chiari malformation, bone & collagen disorders

Question 41

Describe symptom modulation, movement control, and functional optimization stages

Answer 41

• Symptom modulation: high disability, high pain/volatile, symptoms dominate
• Movement control: moderate disability, moderate pain/stable, movement impairments dominate
• Functional optimization: low disability, low to no pain/controlled, performance deficits dominate

Question 42

Describe neck pain with mobility deficits presentation

Answer 42

• Central or unilateral neck pain
• Limited motion that consistently produces symptoms
• Associated (referred) shoulder/UE pain may be present
• ROM limited
• Neck pain at end ranges
• Restricted segmental mobility
• Positive provocation testing
• Deficits with cervicoscapulothoracic strength or motor control

Question 43

Describe neck pain with movement coordination impairments (WAD) presentation

Answer 43

• MOI trauma/whiplash
• Associated (referred) shoulder girdle or UE pain
• Associated varied nonspecific concussive signs & symptoms
• Dizziness/nausea
• HA, concentration, memory, confusion
• Increased affective distress, hypersensitivity to thermal, acoustic, light indoors
• Positive: cranial cervical flexion test, neck flexor endurance test, pressure algometry
• Point tenderness may include myofascial trigger points
• Sensorimotor impairment may include altered muscle activation patterns, proprioceptive deficit, postural balance or control

Question 44

Describe neck pain with headache presentation

Answer 44

• Non-continuous, unilateral neck pain & associated (referred) HA
• HA is precipitated or aggravated by neck movements or sustained positions/postures
• Positive cervical flexion rotation test
• HA reproduced with provocation of the involved upper cervical segments
• Limited cervical ROM
• Restricted upper cervical segmental mobility
• Strength, endurance, & coordination deficits of the neck muscles