L17: Clinical reasoning in management of the elbow 1 Flashcards
1
Q
What are 5 features when designing a suitable management plan for the elbow?
A
- Have completed a comprehensive assessment
- Have developed physiotherapy aims matching with patient’s goals
- e.g. Improve ROM (and which restricting structure), pain, muscle strength, endurance power
- Be aware of clinical efficacy of treatments (ESP)
- Rationalize management based on assessment findings and evidence
- Have measurable outcomes to evaluate change and determine success of management
2
Q
What are 4 considerations of aims for the pathophysiology for the elbow?
A
- Severe and irritable pain - reduce pain
- Nociceptive pain related to tissue injury
- Neuropathic pain in dermatomal or peripheral nerve distribution
- Central sensitisation: Diffuse, disproportionate, illogical pain distribution - be gentle with manual therapy & exercise
3
Q
What is pathophysiology for elbow?
A
Pain processing
4
Q
What are 4 considerations of aims for the pathophysiology for the elbow?
A
- Healing potential: Cartilage, tendons, ligaments have poor healing potential due to poor vascularisation. Muscles have good healing potential.
- Extent of tissue injury: Grade of injury
- Stages of healing: Acute, subacute, chronic stage - precautions & contraindications in different stages
- Chronic - precipitating factors: e.g. Tendinopathy in reactive stage only tolerates low load.
5
Q
What is pathology?
A
Tissue or structures involved
6
Q
What are impairments?
A
Impairments that contribute to or as the result of the injury
7
Q
What are examples of factors related to poor prognosis?
A
e.g. Neck pain in LET
8
Q
Stages of healing for ______ injury (e.g. Tendons, ligaments, muscles)
A
acute soft tissue
9
Q
_____ depends on tissue involved, extent of injury, location of injury
A
Timeframe
10
Q
What are the 3 stages of healing?
A
- Inflammation
- Proliferation
- Remodelling
11
Q
What are the 4 features of inflammation as a stage of healing?
A
- Redness
- Heat
- Swelling
- 48-72 hours
12
Q
What is a management of inflammation as a stage of healing?
A
Reduce pain & inflammation
13
Q
What are 5 features of proliferation as a stage of healing?
A
- Re-vascularisation
- Fibroblasts synthesise collagen
- Scar tissue
- Disorganised collagen
- A few months
14
Q
What are 2 managements of proliferation as a stage of healing?
A
15
Q
What are 4 features of remodelling as a stage of healing?
A
16
Q
What is a management of remodelling as a stage of healing?
A
Address impairments: e.g. Flexibility, neuromuscular control, muscle strength
17
Q
What are 5 features of advice and education for injury?
A
- Pain management: Ice, heat, pain medications (refer to GP/pharmacist)
-
Activity modification: changing postures, loads, frequency, intensity of activities
- If activity modification does not work, then rest for short period till pain settles.
- Correct postures
- Modulation of load
-
Reassurance: prognosis, progress of recovery, address inappropriate beliefs
- Give realistic timeframe. Tricky to give timeframe for chronic conditions - may focus on short-term goals.
18
Q
What is the advice and education for lateral elbow tendinopathy with considerable pain and weakness on gripping?
A
- Activity modification: Most provocative position of gripping is elbow E + pronation (e.g. lifting groceries, kettle bell swings, dumbbell flies, lifting and reaching forward). Change the position into elbow F + supination.
- If cannot change position, then reduce load, intensity, frequency.
- If ineffective, then rest for short periods.
- Pain management: ice, heat, pain medications
- No corticosteroid injections
19
Q
What are 6 purposes of manual therapy?
A
- Pain modulation
- Improve ROM or capsular restriction
- Decrease muscle spasm
- Increase muscle length
- Decrease inflammation
- Improve joint nutrition
20
Q
What are 4 manual therapy techniques?
A
- Passive physiological glides
- Passive accessory glides
- PNF: Hold-relax, contract-relax, rhythmic stabilisation
- Massage: Effleurage, deep tissue massage
21
Q
What are 2 manual therapy techniques to reduce pain?
A
- Passive physiological/accessory glides grade 1-2 in pain-free positions
- Massage effleurage
22
Q
What are 4 manual therapy techniques to improve ROM?
A
- PNF hold-relax, contract-relax
- Massage
- Passive glides grade 3-4
- MWM
23
Q
What are 3 manual therapy techniques to improve muscle spasm?
A
- PNF hold-relax, contract-relax
- Massage
- Passive glides grade 3-4
24
Q
What are 3 features of passive accessory glides?
A
- Accessory glides in restricted position or pain-free position
- Accessory glides in assessment are in open-pack position
- Varying grades depending on aims
- Belt addresses general stiffness post-immobilisation
25
What are the accessory glides for HUJ, RHJ and SRUJ?
26
What are 3 manual therapy techniques for limited elbow flexion ROM following a period of immobilisation for an ulnar fracture? What are 2 progressions?
1. RHJ PA glide
2. HUJ longitudinal glide
3. Elbow distraction for general stiffness
Progression
1. Position of comfort \> into elbow F
2. MWM: RHJ PA glide + elbow F. Elbow medial/lateral glide + elbow F.
27
What are 3 manual therapy techniques for limited elbow extension ROM following a radial head fracture.? What are 3 progressions?
1. HUJ AP glide
2. RHJ AP glide
3. Elbow distraction
Progression using MWM:
1. HUJ AP glide + elbow E
2. RHJ AP glide + elbow E
3. Elbow medial/lateral glide + elbow E
28
What are 2 manual therapy techniques for lateral elbow tendinopathy who has considerable pain and weakness with gripping? What is the home exercise?
TDT to check MWM effectiveness to reduce pain
1. RHJ PA glide + gripping
2. Lateral glide + gripping
Home exercise: MWM self glide + gripping
29
What are 7 purpose of therapeutic exercises?
1. Improve motor control
2. Improve strength, endurance
3. Improve range of motion
4. Increase muscle length
5. Decrease pain or muscle spasm
6. Improve joint nutrition
7. Improve performance of functional or occupational tasks
30
What are 5 considerations of exercise prescription?
1. Specificity of exercise to aim and functional requirements
2. Amount & type of resistance
3. Sets, reps & duration
4. Arm & body position
5. Home exercise program: Ensure they have access to equipment
31
For lateral elbow tendinopathy who has pain and weakness with gripping. What exercises could you teach to improve strength of the wrist extensors? What are 2 progressions?
1. Position: Elbow slight F + forearm pronation supported on table.
* If too provocative, can be in forearm neutral.
2. Isotonic exercise: Concentric + eccentric
3. Dosage: 8-12 reps, pain-free
Progressions
1. Increase load
2. Progress position to elbow E + pronation, reduce support.
32
For lateral elbow tendinopathy with poor control of wrist posture whilst gripping and poor dissociation of wrist from finger extension. What exercises could you prescribe to improve the motor control deficits?
1. Position: Elbow slight F + forearm pronation supported on table. No wrist deviation.
2. Hold a weight in hand, maintain wrist in slight E. Palm sliding exercise: Wrist E by sliding fingers and lifting knuckles (no MCP E).
3. Combine wrist motor control exercise with shoulder IR/ER theraband exercise - control wrist neutral position, no deviation.
33
Valgus instability secondary to repetitive throwing. What exercises could you prescribe to strengthen muscles that could assist with valgus stability? What are 5 ways to improve power of throwing?
1. Strengthen FCU, pronator teres (muscle that cross medial elbow have passive bulk effect and dynamic stability when contract)
2. To improve power of throwing
1. Increase speed of movement
2. Chest passes: Increase distance, RPE of passing
3. Overhead passes
4. Side passes using swiss ball. Double hand \> single hand.
5. Increase shoulder abd
34
What are 6 purpose of electrophysical agents?
1. Decrease pain
2. Alter posture
3. Add stability
4. De-load structures
5. Increase ROM
6. Motor retraining/learning
35
What are 4 taping techniques for the elbow?
1. **Deloading tape** for tennis elbow: Deload wrist extensors, reduce pain. Good for severe/night pain.
2. **Lateral glide tape**: TDT +ve for lateral glide - tape into those positions.
3. **PA glide radius tape**: TDT +ve for radial PA glide - tape into those positions.
4. **Varus/valgus instability taping** for MCL/LCL ligament injury
36
What is an elbow extension splint used for?
Elbow E splint is for reduced elbow E after fractures, if ROM exercises are ineffective.
* Refer to OT to make splint.
37
What is a tennis elbow brace used for?
Tennis elbow brace deloads wrist extensors, reduce pain.
