Fundamentals of MSK Flashcards
What is a differential diagnosis?
Systematic process used to identify the most probably dx from a set of possible competing diagnosses
When does a differential diagnosis begin?
In the hx with a working dx
What does the differential diagnosis direct?
The POC
What should we do when we begin our examination?
Obtain informed consent
What should we know about informed consent?
Specific
benefits and risks
offer options
full understanding
What does a history provide us with?
A mutual patient focused relationship
What should our history questioning begin with?
Open ended questions
When should we use closed ended questions in our history?
To clarify and verify
What kind of questions do we not want in our history?
Leading questions
What does SINSS stand for?
Severity
Irritability
Nature
Stage
Stability
Why do we use SINSS?
Helps determine the vigor and extent of physical exam and intervention as well as prognosis
What is minimal severity?
0-3/10
intermittent pain/limitation/medication
What is moderate severity?
4-7/10
Intermittent and constant pain/limitaiton/medication
What is maximal severity?
8-10/10
constant pain/limitation/severity
What about sleep are we concerned with?
If it is interrupted, influence of positional changes
What do we need to know about medications and supplements?
Dosage - OTC or precription
Frequency
Results
What is minimal irritability?
Easing > aggravating activities
Easier relief and slower aggravation
What is moderate irritability?
Easing = aggravating activities
Similar relief and aggravation timing
What is maximal irritability?
Aggravating > easing activities
Easier aggravation and slower relief
What is a mechanical issue?
Symptoms respond to movement
What is a non-mechanical issue?
Symptoms do NOT respond to movement - RED FLAG
What is nociceptive pain?
MSK or viscerogenic
vague, dull, achy
What is neuropathic pain?
Nervous tissue compromised
paresthesias and/or numbness
What is nociplastic pain?
Mismatched and heightened pain perception
pain that is inflammatory is ….?
sharp
What do patient characteristics such as psychological factors influence?
pain perception
What is a suspicious MSK red flag S&S?
unwillingness to move or splinting after trauma
What qualifies a condition as being acute?
less than 3 weeks
What qualifies a condition as being sub-acute?
3-6 weeks
What qualifies a condition as persistent?
More than 6 weeks
What is high sensitivity better at?
RULING OUT
What parts of the social history should we be concerned with?
Smoking
alcohol
drugs
work
When does observation happen?
From introduction through intervention
What may we observe during conversation?
Slurred speech, hoarseness
What are some structural characteristics we may observe during observation?
Body type, postures, swelling, skin markings, hair quality, asymmetries, othotics, etc.
What is a red flag that we may see during observation?
deformity after trauma
What is our general assessment?
Scan or screen
What is a biomechanical exam?
Greater detailed assessment based on scan findings
What are symptoms?
Reported by/for the patient
What are signs?
Objective; measured by the clinician
Can symptoms be present without signs or impairments?
Yes
What are the 5 purposed of a scan?
- assess for red flag S&S
- assess neuro status
- determine if symptoms are referred or radicular
- assess severity of condition
- identify need for more in-depth biomechanical exam
What does active ROM assess?
Willingness to move, ROM, integrity of contractile and inert tissues, pattern of restriction, quality of motion, and symptom reproduction
What does passive ROM assess?
Integrity of inert and contractile tissues, ROM, end feel, and sensitivity
What does resisted testing assess?
Integrity of contractile tissues
What does stress testing assess?
Integrity of inert tissues
What does neurologic testing assess?
Nerve conduction
What should we scan first without recent trauma?
spine first
What do we scan first with recent trauma?
involved areas first
What is the purpose of selective tissue tension testing?
discerning contractile from non-contractile tissue integrity
What are contractile tissues?
muscles
tendons
fascia
What are non-contractile tissues?
everything else such as cartilage, bones and ligaments
What are the 3 components of a STTT?
A/Prom with overpressure
combined motions
Resisted testing
What do we observe with ROM?
Quantity and quality
What is WNL ROM?
full, pain free, coordinated motion and smooth curves
What does aberrant motion indicate?
joint hypermobility/instability
What do sharp curves or fulcrums in the spine indicate?
Impaired motions
Full quantity of ROM is not always synonymous with …
Normal or efficient motion
What are essential or basic ADLs?
Walking, reaching, squatting, bending, turning, etc.
What are some higher level ADLs?
Lifting, throwing, jumping, running, etc.
What does improved pain/function with repetitive tests indicate?
Possible inhibited muscle, disc injury, etc.
What does worse pain/function with repetitive tests indicate?
Acute injury/irritation
What can a inhibited muscle be due to?
Pain
swelling
disuse/immobilization
joint laxity
What is an end feel?
What the clinician feels at the end of a movement
What type of tissue is indicated if the same pain occurs in the same direction of AROM and PROM?
Non-contractile tissue
What type of tissue is indicated if PROM is similarly restricted as AROM in the same direction?
Hypomobility, protective guarding or a shortened muscle
What is indicated by PROM being significantly greater than AROM in the same direction?
Hypermobility/instability
When should we perform combined motion?
If uniplanar motions don’t provide much if any guiding information
What kind of motions are combined motions usually??
Circumductions
What does a consistent block indicate?
Hypomobility so follow up with accessory motion tests
What does an inconsistent block or crepitus indicate?
Hypermobility/Instability so follow up with stability tests
What does opposing spinal quadrants being consistently blocked indicate?
A fibrotic joint so follow up with accessory motion tests
How long do we hold manual muscle tests?
At least 3 seconds
What would strong and painful resisted testing indicate?
Mild injury
What does weak and painful resisted testing indicate?
Acute, moderate to severe injury
What does a painless and strong resisted testing indicate?
Normal
What does weak and painless resisted testing indicate?
Neurological damage or chronic contractile rupture
What do symptoms upon release of resisted testing indicate?
Non contractile tissue
What do multiple planes of weakness at one joint with resisted testing indicate?
Severe injury
What do multiple joint of weakness indicate with resisted testing?
Possible CNS issue
What does weakness throughout a range and NOT just in mid range indicate with resisted testing?
Possible Pathology
If resisted testing is weak and painful you can retest up to ___ times?
3
When would we NOT perform stress tests?
If known damage, deformity, or fusion
What does pain with the brief force with stress tests indicate?
Acute condition
What would we find with stress tests that would indicate hypermobility?
Late, empty and or soft end feels
click clunk and/or spasm
What does increased pain with distraction indicate?
Capsule ligament or annulus
What does decreased pain with distraction indicate?
Joint surface tissues such as cartilage nucleus pulposus bone or spinal nerve involved
What does decreased pain with compression indicate?
Capsule, ligament, or annulus involved
What does increased pain with compression indicate?
Joint surface tissues such as cartilage nucleus pulposus bone or spinal nerve involved
What does it mean if both distraction and compression produce pain?
Acute condition
What are dematomes? What do they create?
An area of skin sensation supplied by single segmental spinal nerves with considerable overlap, typically creates paresthesias
What are cutaneous nerve distributions?
An area of skin supplied by a peripheral nerve, more distinct boundary; typically creates numbness
What is the first sensation lost?
Light touch
If sensation with light touch is diminished, what do we do next?
Repeat for incrimination of either spinal nerve or cutaneous nerve pattern
If both ligh and sharp touch are WNL but the patient has paresthesias, use the pinwheel to check for…
Hyperesthesias
If loss of light touch check..
Vibration, 2 pt discrimination, and proprioception for possible dorsal column issue
If loss of sharp touch check…
Temperature and crude touch for possible spinothalmic tract issue
What are the grades for neuro tests?
0= absent
1= diminished
2= WNL
3= hyperesthesia
What is deep tendon reflex?
Look from muscle spindle afferents to ventral horn efferents
What are the grades of DTR neurological tests?
0= absent LMN condition
1+ = hyporeflexive; LMN consition
2+ = WNL
3+ = hyperreflexive; UMN condition
4+ clonus > than 3 beats; UMN condition
What are myotomes?
key muscle or group of muscles innervated by single spinal nerve
What do myotomes test for?
Fatiguing weakness
How much conduction loss is needed before percievable fatiguing weakness?
80%
What does dural mobility assess?
Sequential/progressive assessment of neural mechanosensitivity
What are we looking for with dural mobility testing?
Reproduction of achy or sharp symptoms or paresthesias
Slow growing tumors may cause dural mobility to be …
WNL - not much inflammation
What is muscle tone for a LMN condition?
Decreased or flacid
What is muscle tone for a UMN condition?
Increased or spastic
What will a LMN do to the bowel and bladder?
Cause incontinence or leakage
What will a UMN do to the bowel and bladder?
Spastic/retentive
What are dematomes/myotomes findings for a LMN condition?
Often a single segment
What are dermatomes/myotomes findings for a UMN condition?
Multi-segments diminished
What are DTRs with LMN conditions?
Hypoactive
What are DTRs with UMN condition?
Hyperactive
What is accessory motion testing?
Involuntary joint surface motion: roll glide and spin
When do we perform accessory motion?
If limited ROM and/or consistent block during combined motions
Is it easier to pick up joint hypomobility than joint hypermobility?
Hypomobility
What is PPM?
Passive Physiological Mobility - assessing glides with extremity osteokinematic
What is PAM?
Passive accessory mobility - assessing glides without ostokinematics, more often performed in extremities
What is PPIVM?
Passive Physiologic Intervertebral Mobility
- assessing glides with spinal osteokinematics
What is PPAIVM?
Passive physiologic Accessory Intervertebral Mobility - assessing glides without osteokinematics
What is joint hypomobility indicated by in accessory motion?
- limited gliding
- early, firmed end feell
What is joint hypermobility/instability indicated by with accessory motion?
- excessive gliding
- later, softer, and/or empty end feel
- click, clunk, spasm
If accessory motion and ROM limited, then restriction is __________ or related to a joint restriction
Articular
If accessory motion is WNL or excessive but ROM limited then restriction is _____________
Extraarticular
What does accessory motion abnormality indicate?
Improper axis of joint motion and subsequent excessive stress on adjacent tissue
What is a centrode?
Axis
What does the centrode do?
Changes due to gliding and rolling
What are special tests?
More precise than stress tests, may help to identify a more specific tissue, its integrity and assess progress
Why are most special tests not “special”?
Fail to incriminate a tissue, make a dx, or determine an effective intervention as they clain
What are provocative tests?
Identify tissues by the reproduction of tissues
What do provocation assess the integrity of?
Non-contractile tissues
What does segmental play assess for?
Excessive linear shearing or vertebra
When do we perform provocative tests?
If excessive ROM and/or inconsistent block noted with combined motions
How long do we hold provocative tests?
10 secs
What position should we test stability in?
CPP
What do muscle length tests help us determine?
Passive flexibility of muscles
What is sensitivity or SNOUT?
so good at finding positives when the test is negative you can rule the tissue/condition OUT
What is SNOUT good for?
Avoiding false negatives
What is specificity or SPIN?
So good at finding negatives that when the test is positive you can rule the tissue/condition in
What is the acceptable level for sensitivity and specificity?
~90%
What does a likelihood ratio combine?
Sensitivity and specificity
What is the likelihood ratio not affected by?
condition prevlanace
What is a postive likelihood ration?
Likelihood of a positive test when a patietint has the condition - the higher the better
What is a large likelihood shift?
> 10
What is a moderate likelihood shift?
5-10
What is a negative likelihood ratio?
Likelihood of a negative test when the patient does not have the condition; the lower the better
What is a large likelihood shift?
<.1
What is a moderate likelihood shift?
.1-.2
What is MMT?
Typically mid-range with break test and dont let me move you commend
What is the lengthened position in terms of MMT?
Passively insufficient position used to locate milder or grade I muscle strains that were not painful in mid-range
Why do we test MMT in mid-range?
Muscle in strongest position
When is the muscle in its weakest position?
when fully shortened
When is a muscle in a position of passive insufficency?
Fully lengthened
How long do we hold MMT?
At least 3 seconds
Why do we hold MMT for 3 seconds?
To better assess neuromuscular adaptation capacity and NOT max strength
What is MMT not good at finding?
Smaller deficits
What does MMT tend to overestimate?
Strength
Can MMT be used to predict function?
NO
What does it mean when you have symptoms upon release with MMT?
Possible articular issue as glide is released when muscle relaxes
What does it mean when you have multiple planes of weakness at one joint with MMT?
Possible acute and/or significant injury
What does it mean when someone has multiple joint of weakness with MMT?
Possible CNS issue
What does it mean when someone has weakness throughout a range in MMT?
Possible pathology
What does it mean if with repetitive MMT the patient has improved pain / function?
Inhibited muscle and/or regional interdependance
What does it mean if with repetitive test findings a patient has fatiguing weakness?
Decreased nerve conduction
What does it mean if with repetitive tests of MMT a patient has a consistent weak force?
Deconditioned/torn muscle
What does it mean if with repetitive MMT testing a patient has worse pain/function?
Acute injury/irritation
How long should endurance holds be?
Solid for ~20 seconds
What is muscle activation and endurance assessing?
stabilizing, postural and local muscles
What does a warm temp with palpation indicate?
Acuity
What does a cold temp with palpation indicate?
Poor circulation
What does turgor and possible pain with skin rolling?
Dehydration or nociplastic pain
What does watery swelling indicate?
Acuity
What does thickness and pitting swelling indicate?
Chronicity
What is hypertonicity of a muscle? What causes it?
Inhibited muscles that are overworked and protecting
When is hypertonicity palpation not reliable?
in deeper spinal muscles
What is TTP doing?
Localizing involved tissue or deformity such as a fracture or tear
What are the grades of TTP?
0- none
I - mild
II- mod
III - severe
IC - hypersensitive
What kind of diagnosis is rarely made clincally?
Absolute dx
What is hypothetico-deductive reasoning?
methodical investigation of all data from multiple hypotheses
What population uses hypothetico-deductive reasoninc?
More by PT students or when experienced clinicians don’t see a pattern
Is hypothetico-deductive reasoning more analytic or intuitive?
Analytic and slower; deductive reasoning
What is pattern recognition?
A recognizable set of signs and symptoms
Who uses pattern recognition more?
Experienced physical therapists
What is pattern recognition promoted by?
Clinical prediction rules
Is pattern recognition more analytic or intuitive?
Intuitive and efficient; inductive reasoning
When should we use both types of reasoining?
Always to some degree to reduce the error of the other
What are short term goals?
Anticipated interim steps
What are long term goals?
overall outcomes
What is a prognosis?
Predicted level of function in a specified time
What is prognosis based on?
Numerous + and - factors such as severity, PMH, age, time for tissue healing, etc.
What guides the POC?
Prognosis
What is minimal detectable change (MDC)?
Minimal change that exceeds measurement error
What does MDC indicate?
Clinical relevance
What is minimally clinically important difference (MCID)?
measures clinical relevance; more definitive measure of improvement
What is EQ-5D?
commonly used generic instruments; captures quality of life from mobility, self-care, usual activity, pain, and anxiety/depression
What is the Orebro MSK pain screening tool?
A tool designed specifically to facilitate clinical decision making
What is the MSK patient reported outcome measures?
A tool that enables clinicians to quickly evaluate and monitor MSK health status using question s for each health domain
