Lecture 3 - Rule outs Flashcards
list some general rule outs
- joint A/B
- fracture - tap, tuning, squeeze
- arthrological scan axam
- neurological scan exam - during myotomes / dermatomes
- circulation problems- BP etc.
- spinal problems - aching, burning sensation down limbs etc.
- visceral pathology
examples of rule outs: IOS - IVD pathology
Rule out via forward flexion, rotation, side bending, straight leg raise
Refer to physician if you are unsure
explain the james cyriax technique for functional testing
designed to test the joint motions
designed to tell you if contractile or inert structures are involved
Pain at the extremes of movement indicate:
Painful structure is stretched
Painful structure is being compressed
Painful arc indicates:
Impingement
Typically around 60-90 degrees
functional testing general guidelines:
Test bilaterally
Uninjured side first
Most painful test last
Patient comfort
A, P, R vs. A, R, P
Testing influenced by history and observations
Support the injured site well during testing
Document referred pain as you test
Document radiating pain as you test
Ask location of pain throughout testing
Referral of pain is a common occurrence in problems associated with the __ system
MSK
The reference of pain is an indicator of the segment which is _____
dysfunctional - Don’t focus on just the areas of pain recognize the source of pain is likely a disfunction somewhere else
example of functional testing: Pain in the C5 dermatome could arise from:
irritation around C5 nerve root
disc or facet involvement of C4,5
any muscle supplied by the C5 nerve root
any visceral structure having C5 connections
the shoulder joint – something could be impinging the nerve
functional testing for contractile tissue refers to what components of a muscle?
Muscle belly
Tendon
Tendoperiosteal junction
how can tension be applied to contractile structures?
A/P/R
functional testing - inert tissue includes:
Joint capsules
Blood vessels
Skin
Fascia*
Ligaments
Meniscus
Dura mater
Nerve
Cartilage
Bursa
how can tension be applied to inert structures?
Actively moving the joint
Stretching during passive movement
Sometimes tenderness may be elicited by pinching these structures
- fat pad
- anterior capsule of shoulder joint
describe functional testing for active movements
Ask athlete to move the joint through as much ROM as possible
Compare ROM bilaterally
Each physiological movement for the joint is tested
would are the possible results for active “free” movements?
Normal
Limited (hypomobile)
Excessive (hypermobile)
what can active movements tell the therapist?
Active movements tell the therapist;
Athlete’s willingness to move the joint
Athlete’s active joint range
That the muscular strength can move the joint and body part
Painful or not
Trick motions
Joint surface degeneration
what is the method for relaxed passive movements
The therapist lifts the limb through the full possible ROM
Measure or approximate the degrees of motion
Compare the range bilaterally
Each anatomical range of the joint is tested
The athlete must be relaxed
Be gentle
Do not force the joint when there is pain or spasm
what should you record for passive movements
Record:
The range of motion in degrees
If there is pain during any part of the range
Describe the pain and it’s location during the movement
End feel
what are the possible ranges for passive movement?
The range may be;
Normal
Limited (Hypomobile)
Excessive (Hypermobile)
What two patterns of restriction can be present with passive movement?
Restriction can be in;
A capsular pattern
A non-capsular pattern
what does end feel mean?
END-FEEL is the term used to describe the sensation imparted to the therapist’s hand at the extreme of the possible range
what is the end-range sensation for soft tissue approximation?
The limiting factor of joint movement feels “soft” and pressure at the initial end of range of motion easily yields more range.
what are the treatment guidelines for soft tissue approximation with regard to end-feel
Probably easily rehabilitated and full movement restoration will be rapid.
what is the end-range sensation for capsular?
The initial end range of motion can be increased, but resistance is greater and the amount of range increase is smaller.
what are the treatment guidelines for capsular end-feel?
The capsule can be stretched over a period of time, dependant on how firm the capsular end-feel is and the chronicity of symptoms.
what is the end-range sensation for bone on bone
An abrupt end-feel occurs that does not yield more range from the initial end range when pressure is applied.
what are the treatment guidelines for bone on bone end feel?
Small chance of increasing the present range of motion. Manipulation under anesthesia or surgical intervention most likely needed.
what is the end-range sensation for a springy block?
When end range is reached, there is a rebound felt. Intra-articular meniscal displacement is usual cause.
what are the treatment guidelines for a springy-block end feel?
Traction is the only alternative to allow the intra-articular block to move out of the path of movement.
what is the end-range sensation for muscle spasm?
A rapid abrupt stop of movement with muscle tension is apparent.
Spasm end-feel varies many times with range. Avoidable with increases in speed of movement.
what are the treatment guidelines for muscle spasm end feel?
Spasm is secondary to irritation.
Check muscle and joint structures.
Treat for inflammation.
what is the end-range sensation for an empty end-feel?
When moving through the range of motion, no resistance is felt regarding the joint surfaces, but at a point in the range the client will voluntarily contract the muscles and stop further movement. An abrupt unexpected stop of movement.
what are the treatment guidelines for an empty end-feel?
This end-feel can indicate major problems in tissue around and serving the joint. It can also be of psychological origin. Usually the end range does not vary with speed of movement as it does with a spasm end-feel.
what are some normal end feels?
Bone on Bone
Soft Tissue Approximation
Capsular – feeling a capsular end feel is normal depending on joint
Soft Tissue Stretch
what are some abnormal end-feels?
Bone on Bone
Muscle Spasm
Capsular
Springy Block
Empty
Soft Tissue Approximation
what are some key guidelines for resisted isometric contractions?
Isometric
Only the muscle working
build contraction gradually
Be sure to adjust the therapist position so you can resist the athlete when they are working as hard as possible
When positive each contraction should be done in inner, middle and outer ranges
what is the method for resisted isometric contractions?
Ask the athlete to attempt a joint movement while the remainder of the limb or body is stabilized
Stabilization is needed to minimize substitution and minimize joint movement
Muscle groups are tested and if a weakness is found individual muscles should be tested
Therapist and athlete build to a maximal contraction gradually disallowing any joint movement
Each muscle and tendon are tested in a position that best isolates them
They are at optimal length for a maximal contraction
The amount of therapist pressure depends on the part being tested, the leverage and the strength of the athlete
Instruct the athlete when the resistance will start and coach them on the length of contraction with a slow cessation of pressure
Muscles other than those being tested must not be included
(i.e. Elbow resistance at hand vs. above wrist)
Athlete must be encouraged to try their hardest
(NB cannot resist plantar flexors manually)
what should the therapist record for resisted isometric contractions?
The degree of strength on a scale from 0-5:
Gone 0 – no contraction left
Trace 1 – muscle can be felt to tighten, but cannot produce movement
Poor 2 – produces movement with gravity eliminated, but cannot function against gravity
Fair 3 – can raise part against gravity
Good 4 – can raise part against outside resistance as well as against gravity
Normal 5 – can overcome a greater amount of resistance than a good muscle
Whether the test is painful or pain free
record where there is pain during the contraction
record when there is pain during the contraction
Ex. Did the pain come immediately or at the end
what can the results of resisted isometric contractions show?
weakness can be due to a neurological deficit or actual loss of strength of the muscle or tendon
appropriate neurological testing can rule this out
It is important to determine true weakness from apparent weakness due to pain or an unwillingness of the athlete to exert the muscle
For resisted isometric contractions - Possible combinations of other strength and pain factors include:
Strong and Painless
Strong and Painful
Weak and Painless
Weak and Painful
what is the significance of resisted isometric contractions?
These movements test the state of the contractile structures and their nerve supply
how do you determine “normal” in relation to muscle testing?
Bilateral on each patient
Build a basis for comparison of test results through experience in muscle testing
Test a series of individuals of various ages and activity levels both male and female
Test persons with faulty posture as well as those with good posture
The grade strength (0-5) of the muscle will indicate how to plan a program for muscle re-education
This will be used as a sign for continual reassessment
What conditions could you have if you have pain and limitation in every direction with passive movement when the whole joint is affected.
Pain and limitation in every direction when the whole joint is affected is arthritis or capsulitis
T/F Each joint has its own “capsular” pattern with different limitations in each direction
True
