Interventions Lecture 1 Flashcards
Musculoskeletal Diagnosis..Now what? - What 2 things should you consider
- Evaluation procedures: determine the source and degree of dysfunction
- Tissue healing parameters
When setting up a treatment plan, what factors will you consider?
- tissues involved
- precautions
- pt’s normal activities
- how much skilled PT is required
- how long pt will have access to skilled care
- what has worked for similar patients
- your skill level as a PT
- any referalls required
Impairments being treated must be related to
functional deficits
Intervention decisions are based on
-normal tissue healing; modified based on patient response to treatment
Inflammation, pain, an edema must be addressed ___ to more agressive or manual therapy
BEFORE
All programs must include a
self-management component
A facture is a
“soft tissue injury with a broken bone underneath it”
Fracture considerations
- Location
- Configuration
- Extent
- skin
- soft tissue injury
Fracture healing inflammatory phase
- Hematoma formation
- Cell proliferation
Fracture healing reparative phase
- soft callus unites the site
- ossification: hard callus
Fracture healing remodeling phase
-consolidation and remodeling of bone
Children healing time from fracture
4-6 weeks
Adolescents healing time for a fracture
6-8 weeks
adult healing time for a fracture
8+ weeks
Fracture medical management
- closed reduction
- open reduction internal fixation
- external fixator
- skeletal traction
Effects of immobilization
- Sluggish circulation
- Muscle atrophy
- articular cartilage degeneration
- joint adhesions
- contracture development
- connective tissue weakening
PT Role in fracture management during immobilization
- minimize complications
- decrease effects of inflmmation
- decrease effects of immobilization on non-involved joints
- maintain ROM/strength in major muscle groups
- teach functional adaptations
- maintain CV conditoning
PT Role in fractures post-immobilization
Increase joint mobility/ROM Increase strength/stability Weight bearing progression (LE) Increase propioception/fine motor control correct faulty movement patterns return to function
Post-immobilization considerations
-Immobilization of soft tissues
- weakned 2deg lack of activity
-inelastic soft tissue 2deg of scarring
Pt likely to be painful when starting to move
Progress stretching, strengthening, balance and functional activites per gudeliens for subacute/chronic stages
*MONITOR TISSUE RESPONSE
Bone spurs do not equal
pain/inflammation
wolf’s law
bone in a healthy person or animal will adapt to the loads under which it is placed
Bone spur interventions
- decrease inflammation
- find the source of biomechenical stress & minimize it
- compression
- postural stresses
- movement dysfunction/control
- strenght
- ROM
OA does not equal
pain; no relationship between the amount of degeneration and pain level/function
PT intervention goals for OA
- decrease stiffness
- decrease pain (@ rest & from mechanical stresses)
- increase ROM
- prevent deformities
- improive physical conditioning
- improve overall function
Cemented joint replacements
WBAT
Non-cemented joint replacements
NWB/TTWB
Early post-op healing for joint replacements
ROM, joint protection, function w/ assisted device
Late healing for joint replacement
ROM, strength, Increase function
Protocols & joint replacements
-must be strictly adhered to when provided
dysfunction
loss of normal function of a tissue/region
joint dysfunction
loss of normal joint mobility
contractures
adaptive shortening fo skin, fascia, muscle etc
adhesions
abnormal collagen fibers to surrounding structure
reflex muscle guarding
prolonged contraction of a muscle in response to a painful stimuli
Intrinsic Muscle spasm
prolonged contractions of a muscle in response to local circulatory or metabolic changes when the muscle is in a state of prolonged contraction
Conditions resulting in soft tissue pathology
- muscle weakness
- compartment syndromes; increased interstital pressure in a closed myofascial compartment
Grade 1 tear
- few fibers
- mild pain
- minimal; no swelling
- local tenderness
- pain with stress; no laxity
- no/minor functional loss
grade II tear
- approx 1/2 of the fibers
- (+) swelling
- moderate pain with stress/palpation
- moderate-major functional loss
Grade III tear
- all fibers
- severe pain (++) swelling
- local tenderness
- no pain with stress
- joint instability ?
- moderate-major functional loss
Non-contractile tissue injuries
- sprains (ligaments) (grade I, II, III)
- Capsules (hyper vs. hypo)
- internal derangement
- loose bodies
- articular cartilage
- nerve lesions
Contractile tissue injuries
- strains
- contusion
- tendiopathy
Contusions first degree
- microscopic deformation of tissue
- mild-moderaate inflammatory response
- minimal discomfort
- mild-moderate disability
- no palpable defect
2nd degree contusion
- more painful
- significant inflammatory response
- may limit extreme ROM and strength
- moderate deformation of tissu e
- palpable defect on exam
3rd degree contusion
- maximal tissue deformation
- significant inflammatory response
- more pain
- more swelling
- more bleeding
- interventions: based on the stage of the injury
Contusion contraindications/precautions
Acutely: no heat/thermal use
limit stress placed on tissue early in healing; dont want to increase bleeding
myositis ossifications
calcification within the muscle (quad femoris, bicep brachii, hamstrings)
Strain within the muscle itself grade 1
strong, some pain
strain within the muscle itself grade 2
weak, and painful
strain within the muscle itself grade III
weak and painless
tendinopathy
activity limiting condition typically characterized by thickening/swelling, localized tendon pain and loss of function
tenosynovitis
acute or chronic inflammation or fibrosis of the synovial sheath around the tendon
enthesopathy/enthesitis
injuries/irritation of the enthesisis
primary tendinopathy
no predisposing medical condition or event to blame for the occurence of tendon pathology
(+) mechanical factors or advancing age
Secondary tendinopathy
distinctly related to another medical conditon or event
Primary tendinopathy acute traumatic
- triggered by an inciting event (contusion, surgical procedure)
- typical soft tissue stages of inflammation and repair
- abundant type III collagen
- hypervascularity
- may be fibrosis and adhesions between tendon and surrounding sheath/bursa
- increased cross-sectional area of tendion
Primary tendinopathy acute overuse
- associated with history of repetitive or altered loading
- preceding period of cumulative damage to tendon that was asymptomatic
- < 4 weeks: indications of active inflammation/repair
Primary tendionopathy chronic
- failed healing model
- healthy tendon: able to adapt to loads within the load capacity
- with aging or sedentary behavior, load capacity and adaptive responses decline
- risk factors: diabetes, high cholestor, family history
- when cumulative load exceeds ability to adapt injury becomes accumulate - decreases load capacity
Tendon stress strain curve
control vs tendinopathy
areas with microstructural disturbances experienced higher localized strains during loading
primary tendinopathy chronic (2)
- proliferation of sensory nn and blood vessels
- disorganized collagen; higher type III and GAG
- thickening of the tendon
- chronic inflammation-repair features; fibrin, fibroblasts, mast cells
- calcification present on imaging
- absence of neutrophils
Tendinopathic tissue
- hypercellular and hypervascular
- increaed sensory innervation
- higher water/GAG content
- smaller, disorganized, collagen fibers
- thickening of tendon
primary tendinopathy history
- recent change in loading
- pain during/after tendon loading activity
- pain in the tendon (can also be general)
- gradual onset
- longstanding complaints
- thickening and tender when palpating
- decreased ROM/flexibility
- decreased strength
- pain with loading acitivites
- movement dysfunction
Patient Education (tendinopathy)
-nature of condition and likely cause
-how to mitigate symptoms
competitive athletes: typically need to stop activity
-recreational activities: equal success rates with/without stopping activity
NOT a straightforward answer
-pain monitoring approach: 5/10 pain is OK - anything more; stop
tendinopathy resistance training
- strength, power, endurance deficits in tendinopathy are well documented
- resistance exercise improves the rate of clinical improvement in tendinopathy
- eccentric exercise; not a stand-alone Rx
- can result in muscle lengthening (add sarcomeres)
- in theory, this can reduce strain through the tendon
Resistance training analgesic effect
small reproduction in pain following resistance training
NOT dependent on the type of muscle contraction
Tendinopathy stretching
include if ROM/length deficits are present
-sport specific dynamic stretching before activity recommended during the return to sport phase
Neuromuscular training tendinopathy
- focus initially on quality and control of motion
- patient education/coaching
- manual cueing
- self-monitoring
- integrate entire kinetic chain
- later increase load and integrate functional activites
Other interventions for tendinopathy
manual therapy dry needling taping/bracing -reduce pain during work/spirt -improve patient confidence -improve propioception -improve muscle strength and endurance
