Intro to MSK Flashcards
what are the 3 problem solving methods utilized within PT?
- Pattern recognition (System I)
- Hypothetico-deductive (System II)
- Mixed
what is pattern recognition (System I)?
developing scripts or prototypes based off of patterns
- forward reasoning
- faster
- more efficient
what is hypothetico-deductive (System II) problem solving?
gathering a lot of info during examination and then going back to think about what the info means
- backward reasoning
- heavy reliance in novice practice
- utilized by experts when faced with unfamiliar presentations
what is causal reasoning?
forming inferences from clinical findings
determing cause and effect relationship of variabels
based on normal/abnormal physiology
be careful! lots of assumptions can be made!
what is case-based reasoning?
knowledge stored in symbolic “script”
based on previous experiences with other cases, pattern recognition
what is narrative reasoning?
concerns the understanding of patients’ stories in order to gain insight into their experiences of disability or pain and their subsuquent beliefs, feelings, and health behaviors
how do PTs go about reducing uncertainty when forming a diagnosis?
utilizing an elimination, confirmation, and discrimination strategies at various points throughout the examination process
what is the elimination strategy?
seeking data to reduce suspicion of unlikely hypothesis
look for tests that have low negative likelihood ratios
what is a negative likelihood ratio? what is considered a significant ratio?
this tells us how many times more likely a negative test will be seen in those with the disorder than those without the disorder
values <0.2 of importance
values <0.1 of significant importance
what is a confirmation strategy?
seeking data to support a highly likely hypothesis
do these later in the examination
look for tests with a high positive likelihood ratio
what is a positive likelihood ratio? what is considered a significant ratio?
tells us how many times more likely a positive test will be seen in those with the disorder than those without the disorder
values of >5 of importance
values of >10 of significant importance
fill in the blank:
low (-LR) good for ___________
refuting a diagnositic hypothesis
fill in the blank:
high (LR+) good for _____________
confirming a diagnostic hypothesis
what is a discrimination strategy?
seeking info to discriminate between likely hypothesis
(“how to tell the difference between 2 different ducks”)
what are the elements to consider when forming an initial hypothesis?
- non-musculoskeletal health conditions and serious musculoskeletal conditions
- potential radicular and referral sources
- screening adjacent joint regions
- differentiating local MSK conditions
List the steps in the diagnostic process
- Chart Review/Patient Interview
- Visual Inspection
- Systems Review
- Elimination Tests
- Structural Stress Tests
- Palpation and Joint Mobility Tests
- Confirmation Tests
- Diagnostic Hypothesis
what is the PSFS?
Patient Specific Functional Scale
score of 0-10 in which an individual rates activites and their ability to perform that activity
0 = unable
10 = able to at the same level prior to injury
what do red flags during the diagnostic process mean?
s/s consistent with a non-musculoskeletal origin or a serious musculoskeletal health condition that requires referral to another clinician
what do yellow flags during the diagnostic process mean?
indicate need for more extensive examination or cautions/contraindications to certain tests/interventions
what is included during the visual inspection?
- status
- affect
- anthropometrics
- preferred positions
- integumentary
- posture
when assessing posture during the visual inspection, what are you looking for?
- gross abnormalities
- symmetry
- bony/soft contours
- resting posture vs ability to correct
what is the difference between the systems review and elimination tests?
systems review = test to determine if there is a need for further examination
elimination tests = screen for health conditions commonly associated with the diagnostic hypothesis
What neurologic screens/tests are performed during elimination testing?
- sensation
- light touch
- pin prick
- proprioception
- Motor function
- myotome vs peripheral nerve
- coordination
- Reflexes
- DTR
- pathologic reflexes (present or absent)
- Considerations
- symmetry
- normal/diminished/absent
what does the Beighton’s scale look at?
hyperlaxity
What types of things are you assessing for during joint mobility testing?
- symptom provocation
- quality (normal, mechanical block, guarded)
- quantity (joint integrity, hyper/hypomobile, normal)
- willingness to move
when are confirmation tests performed usually?
once hypothesis has been narrowed
these have a high +LR and high specificity
what is the difference between repetitive stress injuries and trauma?
repetitive stress - low intensity of loading, high frequency and or duration (ex. spondylolysthesis)
trauma - high intensity of loading, low frequency (ex. fractured vertebrae)
list the phases of tissue healing
- phase 1 - acute inflammatory response
- phase 2 - repair and regeneration
- phase 3 (4) - remodeling and maturation
what is required for healing to occur?
- controlled forces necessary to facilitate tissue synthesis
- protection from excessive and harmful stresses on tissues
describe phase 1 of healing with a ligament injury
first 3 days
acute inflammatory response and hematoma formation
describe phase 2 of healing with a ligament injury
2-3 days post-injury to 6 weeks
fibroblasts produce collagen
matrix is disorganized
describe phase 3 of healing with a ligament injury
>/= 12 months post injury
collagen fibers become more parallel/organized
increased tissue contraction and tensile strength
List the healing requirements for a ligament injury
- disrupted tissue must remain in continuity
- controlled forces necessary to facilitate collagen synthesis (tensile loading)
- protection from harmful stresses on tissues
describe phase 2 of healing with a tendon injury
begins within the first week
increased fibroblasts/fibroblastic activity through week 4
collagen fibers initially formed disorganized and at random
cells and collagen become more aligned and perpendicular to long axis over time
describe phase 3 of healing with a tendon injury
remodeling
collagen/cells re-alignment typically complete by ~2 months
define tenosynovitis
inflammation of synovial sheath surrounding tendon
how is tendonitis different from tendinosis?
tendonitis = inflammation of tendon
tendinosis = degeneration of collagen tissue in tendons due to aging, microtrauma, or vascular compromise
there is no inflammatory process in tendinosis
what can cause an injury to articular cartilage?
loss of proteoglycans
mechanical injury
what are the 2 subtypes of mechanical injury to cartilage (based on location)?
chondral
subchondral
T/F: there is an inflammatory process during a chondral mechanical injury to articular cartilage
FALSE
limited response that doesn’t reach the blood supply to the cartilage thus no inflammatory response
describe a subchondral mechanical injury to articular cartilage
injury is deeper and extends all the way to blood supply
fills in with tissue more like fibrocartilage (rather than hyaline cartilage) - known as a fibrin clot (forms by 48 hrs)
after 2 months it will resemble “normal cartilage”
how is the fibrin clot suseptible to injury?
fibrocartilage accepts load differently than hyaline cartilage thus it won’t dissipate force in the same way
result is more load on border of the region which can lead to further injury or total dislodgement of the fibrocartilage plug
how long should bone be immbolized following a fracture?
adults = 6-8 weeks
children = 4-6 weeks
early excessive loading of a fracture bone can increase the risk of what?
pseudoarthosis - the region fails to fuse back together and the region of the bone growth fails to process into bone but rather stays cartilaginous
What is the difference between fatigue and insufficency fractures?
fatigue fracture = normal bone put under abnormal stress
insufficency fracture = normal stress put on abnormal bone
list symptoms for a stress fracture
- focal pain
- exercise-induced pain
- night pain
When reviewing a pt chart, what Hx factors will prompt us to think a stress fracture is likely?
- insidious onset of pain that is progressive
- ADLs/performance affected more so with progression
- continual pain with later pathological progression
- pt had an increase in training intensity (prior 6-8 weeks)
- risk factors:
- female
- amenorrhea
- smoking
- prolonged steroid use
what findings during a physical exam point towards a stress fracture?
- local tenderness
- limited ROM at joint area
- palpable guarding
- possible local swelling
- must be confirmed with imaging (MRI or bone scan)
List several secondary response to injury
- arthogenic muscle inhibition
- guarding
- ectopic calcification
- atrophy
- contracture
- anxiety/fear
what is arthogenic muscle inhibition?
described as a continued reflex inhibition of musculature surrounding a joint following injury or joint effusion
(*think how ACLr results in quads not being able to fire as much)
what is guarding (how is it different than AMI)?
increase in the resting activity of a muscle related to a protective response from painful stimuli
AMI - inhibits muscles from activating around the joint vs Guarding - increases muscle activity around the joint
what is ectopic calcification?
accumulation of osteoid material in soft tissue
ex: capsule calcified or bone is integrated into muscle
what are the 2 types of instability?
Neuromuscular/Functional (what we think of)
Structural (what most HCP think of)
