MSK Interventions Flashcards
Define decubitus ulcers
- Synonymous with pressure ulcers
Describe the grades/severity of tissue injuries
- Grade 1: mild pain & swelling and pain with tissue tensoin
- Grade 2: moderate pain & swelling requiring activity modification; tissue is focally tender to palpation; partial ligament tear may result in some increased joint laxity
- Grade 3: near-complete or complete tear with severe pain; minimal or no pain with tissue tension; palpable defect; complete ligament tear will result in joint laxity
Describe the inflammatory stage of healing
- Begins immediately and lasts 3-5 days
- Injured cells release prostaglandins & bradykinin to initiate the inflammatory response
- Platelets form a plug to contain bleeding
- Vasodilation occurs to increase blood flow to area
- Damaged tissue is removed
Describe the proliferation stage of healing
- Lasts from 48hrs to 6-8 wks
- Fibroblasts resorb collagen & synthesize new collagen
- Decreased macrophages & fibroblasts with corresponding scar formation
Describe the remodeling stage of healing
- Tissue will continue to remodal and mature for 1-2 yrs post-injury
- Increased organization of extracellular matrix
- Collagen begins to organize into randomly placed fibrils
Healing timelines for muscle
- Delayed onset muscle soreness (DOMS): 0-3 days
- Grade 1 strain: 0-4wks
- Grade 2 strain: 3-12wks
- Grade 3 strain: 4wks to 6 months
Healing timelines for tendons and ligaments
- Tendon: 8wks to 6 months
- Grade 1 ligament sprain: 0-4wks
- Grade 2 sprain: 3wks to 6 months
- Grade 3 sprain: 5wks to >1yr
Healing timeline for bone injury/fracture
- Bone: 6-12 weeks
- Cartilage (fibrocartilage): 8wks to 12 months
Define autonomic versus mechanical soft tissue/myofascial techniques
- Autonomic: stimulation of skin & superficial fascia to facilitate a decrease in muscle tension
- Mechanical: movement of skin, fascia, & muscle causes histological & mechanical changes to occur in soft tissues to produce improved mobility & function
Indications for soft tissue/myofascial techniques
- Patients with soft tissue & joint restriction that results in pain & limits ADLs
contraindications for soft tissue/myofascial techniques
- Soft tissue breakdown
- Infection
- Skin disease
- Cellulitis
- Osteomyelitis
- Contagious illness
- Malignant tumor
- Aneurysms
Describe soft tissue without motion technique
- Hands do not slide over skin instead they stay in contact with skin while hands & skin move together over the muscle
- Direction of force is parallel to muscle fibers & total stroke time should be 5-7 seconds
Describe soft tissue with passive pumping technique
- Place muscle in shortened position and with one hand place tension on muscle parallel to muscle fibers
- Other hand passively lengthens muscle and simultaneously gradually releases tension of hand in contact with muscle
Describe soft tissue with active pumping technique
- Place muscle in lengthened position and with one hand place tension on muscle perpendicular to muscle fibers
- Other hand guides limb as patient actively shortens muscle
- As muscle shortens gradually release tension of hand in contact with muscle
Describe transverse friction massage
- Used to initiate an acute inflammatory response for a tissue that is in metabolic stasis, such as tendonosis
- Performed for 5-10 minutes
- Involved tendon is briskly massaged in a transverse fashion (perpendicular to muscle fibers)
What is Feldenkrais technique
- Lymphatic drainage technique
- Facilitates development of normal movement patterns
Describe PNF hold-relax-contract technique
- Antagonist of the shortened muscle is contracted to achieve reciprocal inhibition & increased range
What are Maitland’s 4 grades of joint mobilization
- Grade I: small amplitude before the beginning of tissue resistance
- Grade II: large amplitude before the beginning of tissue resistance
- Grade III: large amplitude into tissue resistance
- Grade IV: small amplitude into tissue resistance
- Grade V: high-velocity, low amplitude thrust at the end of joint movement
Absolute contraindications in mobilizations, manipulations, & traction
- Ankyloses
- Malignancy
- Diseases that affect the integrity of ligaments
- Arterial insufficiency
- Active inflammatory and/or infectious process
Signs and symptoms of the “opioid overdose triad”
- Pinpoint pupils
- Respiratory depression
- Unconsciousness
Describe an autologous chondrocyte implantation
- Chondrocytes harvested from lesser weight bearing area of a joint
- Chondrocyte volume expanded in monolayer culture
- Re-implanted in the damaged region under a natural or synthetic membrane via an open joint procedure
- Indication: full thickness cartilage defects
- Contraindication: severe osteoarthritis
Describe platelet rich plasma therapy
- Blood collected from pt & separated into components
- Preparation of autologous plasma enriched with platelets is injected into target site
- Supplies supra physiologic amounts of essential growth factors & cytokines to provide a stimulus for tissues with low healing potential
Indications for platelet rich plasma therapy
- Tendiopathies
- Osteoarthritis
- Ulnar collateral ligament injury
- Meniscus
Contraindications to platelet rich plasma therapy
- Severe osteoarthritis
- Prosthetic joints
Describe stem cell therapy
- Mesenchymal stem cells harvested from bone marrow & concentrated in a centrifuge
- Preparation is injected into the site of injury to attempt to stimulate healing
Indications for stem cell therapy
- Osteoarthritis
- Muscle injuries
Contraindications for stem cell therapy
- Severe osteoarthritis
- Prosthetic joints
Define malingering (symptom magnification syndrome)
- Behavioral response where displays of symptoms control the life of the patient leading to functional disability
Tests to evaluate malingering back pain may include
- Hoover test: assesses the amount of pressure placed on hands from patient’s heels when asked to raise on LE while in a supine position
- Burn’s test: requires patient to kneel & bend over a chair to touch the floor
- Waddell’s signs evaluate tenderness, simulation tests, distraction tests, regional disturbances, & overreaction
Level I evidence for hamstring strain injury prevention interventions
- Nordic hamstring exercise
- Warm-up, stretching, stability, strengthening, & functional movements
Evidence for management of TKA interventions
- Level I: motor function training
Prognostic factors to consider for management of a TKA
- Higher BMI associated with more post-op complications/worse outcomes
- Depression associated with worse outcomes
- Pre-op ROM associated with post-op ROM
- Pre-op strength/function associated with post-op function
- More comorbidity associated with worse outcomes
Pros and cons of a hamstring graft for ACL reconstruction
- Pros: few symptoms post-op; greater return to pre injury level of activity; allows earlier rehab
- Cons: more expensive; believed to be more technically difficult procedure; rehab can be more difficult (slower)
Pros and cons of a patella tendon graft for ACL reconstruction
- Pros: better at maintaining graft tension post-op; less expensive; faster healing time
- Cons: increased potential for anterior knee pain/later patellar femoral osteoarthrosis; increased potential for knee extension deficit; potential delay in rehab 2ndy to more atrophy of quads
Level I evidence for LBP interventions
- Thrust/non-thrust joint mobs to reduce pain/disability in pts with acute LBP and/or chronic LBP
- Trunk muscle strengthening/endurance, specific trunk muscle activation exercise, aerobic exercise, aquatic exercise, or general exercise
Level II evidence for neck pain with mobility deficits interventions
- Acute: thoracic manipulation, neck ROM, scapulothoracic & UE stretching and strengthening
- Subacute: neck and shoulder girdle endurance
- Chronic: thoracic manip, cervical mob/manip, neuromuscular exercises, stretching, strengthening, endurance, aerobic conditioning, cognitive, dry needling, intermittent traction
Level II evidence for acute neck pain with movement coordination impairments (including WAD) interventions
- Advice to remain active
- Education to return to pre accident activities ASAP
- Minimize use of cervical collar
- Perform postural/mobility exercises to decrease pain & increase ROM
- Reassurances that recovery will occur within first 2-3 months
- Multimodal interventions including mobilization, strengthening, endurance, flexibility, postural, aerobic for those pts predicted to have a moderate to slow recovery
Level II evidence for neck pain with headache interventions
- Acute: supervised active mobility exercises
- Subacute: cervical mobilization/manipulation
- Chronic: cervical/thoracic mobilization/manipulation, shoulder girdle & neck stretching, endurance and strengthening
Level II evidence for chronic neck pain with radiating pain interventions
- Stretching
- Strengthening
- Cervical/thoracic mobilization/manipulation
- Education & counseling to participate in activities & movement
- Mechanical intermittent cervical traction
Level I interventions for heel pain-plantar fasciitis
- Should use joint & soft tissue mobilization
- Should use dry needling in the gastroc, soleus, & plantar muscles of the foot
- Should include motor function training
- Should use either rigid or elastic taping in conjunction with other PT treatments
- Should prescribe night splints for 1-2 months
- Should NOT use ultrasound
Level I evidence for Achilles’ tendinopathy interventions
- Mechanical loading (eccentric or heavy load, slow velocity) exercise to decrease pain and increase function
Level I evidence for ankle ligament sprain interventions
- Primary prevention should prescribe prophylactic bracing
- 2ndy prevention should prescribe prophylactic bracing & proprioception/balance training
- For severe injuries, may immobilize for up to 10 days post-injury
- Should implement structured therapeutic exercise program
- Should use manual therapy in conjunction with exercise to reduce swelling, improve mobility, and normalize gait
- Should NOT use ultrasound
Level I evidence for patella femoral pain interventions
- Should consider foot orthoses, patellar taping, patellar mobs, & LE stretching
- Should include both hip & knee exercises
- Hip exercises should target posterolateral hip muscles
- Knee exercises may include weight bearing or non-weight bearing exercises
- Should NOT dry needle
- Should NOT use manual therapy as a stand alone treatment
Level II evidence for meniscal/articular cartilage lesions interventions
- Early progressive knee motion
- Supervised rehab program
- Progressive ROM exercises, strength training for knee/hip, & neuromuscular training
- NMES to increase quad strength. functional performance, & knee function
- Stepwise progression of weight bearing following surgery to reach full weight bearing at 6-8wks
Level I evidence for knee ligament sprain interventions
- Concentric/eccentric exercises in non-weight bearing & weight bearing status starting with 4-6wks & continuing up to 10mo
- NMES following reconstruction surgery (up to 6-8wks)
- Neuromuscular reeducation along with strengthening in patients with knee instability & movement coordination impairments
Level I evidence for older adults with hip fracture interventions
- Across the entire episode of care you MUST provide structured exercise, to include progressive high-intensity resistance exercise (weight bearing & non-weight bearing), balance training, & functional mobility training
- Patient education to maximize safe physical activity
- Should prescribe a multidisciplinary orthogeriatric program
Level II evidence for non-arthritic hip pain interventions
- Movement pattern training
- Therapeutic exercises/activties to address identified joint mobility, muscle flexibility, & strength deficits
- Patient education and counseling
Level II evidence for carpal tunnel syndrome interventions
- Should recommend neutral positioned wrist orthoses worn at night for short-term symptom relief & functional improvement
- Should NOT use low-level laser therapy or iontophoresis or use/recommend magnets
CPG for diagnosing carpal tunnel syndrome
- Need 3 of the following to diagnose
- Age >45
- Shaking hands relieves symptoms
- Sensory loss in the thumb
- Wrist ratio index >0.67
- CTQ-SSS score >1.9
Level II evidence for lateral elbow pain interventions
- Therapeutic exercises with isometric, concentric, and/or eccentric wrist extension exercise for subacute or chronic lateral elbow tendinopathy
- Should use local elbow manual therapy to reduce short-term pain & increase grip strength
- Should use resisted wrist extension exercises in combination with other interventions, including manual therapy
- Should use rigid taping for short-term pain relief in patients with irritable pain
- Should use either tendon or trigger point dry needling for treating pain
Level I evidence for adhesive capsulitis (Frozen shoulder) interventions
- Intra-articular corticosteroid injections combined with shoulder mobility & stretching provide short-term (4-6wks) pain relief & improved function as compared to exercises alone
Special tests to confirm a full thickness supraspinatus tear
- Jobe (empty can)
- Full can
- ER lag sign
Special tests to confirm a full thickness infraspinatus tear
- ER lag sing
Special tests to confirm a full thickness subscapularis tear
- Lift off and belly press OR belly press and bear hug
Special tests to confirm a RTC tendinopathy/partial tear
- Painful arc test
Sort A level evidence for RTC interventions
- Consider corticosteroid injection to reduce pain & short-term disability in patients with severe/persistent pain associated with rotator cuff tendinopathy
- Use an active rehab program as the initial treatment to reduce pain/disability
- Subacromial decompression is NOT recommended even if initial non-surgical management failed
Level I evidence for post-op management interventions of glenohumeral joint arthritis
- Should use a sling & progressive ROM & strengthening exercises to improve reported outcomes & ROM
Examination CPG to diagnose hip OA
- Hip IR <24º or IR/flexion 15º less than non painful side
- Passive IR increases pain
- Morning hip stiffness after awakening
- Moderate anterior or lateral hip pain when weight bearing
Level I evidence for hip OA interventions
- Flexibility, strengthening, & endurance (dosage 1-5x per wk for 6-12wks with mild to moderate hip OA)
- Manual therapy for mild to moderate hip OA that may include soft tissue mobilization, thrust, & non thrust (dosage 1-3x per wk over 6-12wks)
